CRCR Exam Latest: Understanding Healthcare Billing and Reimbursement, Exams of Nursing

Download CRCR Exam Latest: Understanding Healthcare Billing and Reimbursement and more Exams Nursing in PDF only on Docsity! CRCR Exam Latest CRCR Exam Latest Exam 2025 (Questions With Verified Answers) Guaranteed Pass 100% In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? Case rates What are collection agency fees based on? A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? Birthday What customer service improvements might improve the patient accounts department? Holding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? Inform a Medicare beneficiary that Medicare may not pay for the order or service What type of account adjustment results from the patient's unwillingness to pay for a self-pay balance? Bad debt adjustment CRCR Exam Latest What is the initial hospice benefit? Two 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? If the patient requires ambulance transportation to a skilled nursing facility How should a provider resolve a late-charge credit posted after an account is billed? Post a late-charge adjustment to the account an increase in the dollars aged greater than 90 days from date of service indicate what about accounts They are not being processed in a timely manner What is an advantage of a preregistration program? It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? Medically unnecessary services and custodial care What core financial activities are resolved within patient access? Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts CRCR Exam Latest What are hospitals required to do for Medicare credit balance accounts? They result in lost reimbursement and additional cost to collect When an undue delay of payment results from a dispute between the patient and the third party payer, who is responsible for payment? Patient Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: A valid CPT or HCPCS code With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what? Access their information and perform functions on-line What date is required on all CMS 1500 claim forms? onset date of current illness What does scheduling allow provider staff to do Review appropriateness of the service request What code is used to report the provider's most common semiprivate room rate? Condition code CRCR Exam Latest Regulations and requirements for coding accountable care organizations, which allows providers to begin creating these organizations, were finalized in: 2012 What is a primary responsibility of the Recover Audit Contractor? To correctly identify proper payments for Medicare Part A & B claims How must providers handle credit balances? Comply with state statutes concerning reporting credit balance Insurance verification results in what? The accurate identification of the patient's eligibility and benefits What form is used to bill Medicare for rural health clinics? CMS 1500 What activities are completed when a scheduled pre-registered patient arrives for service? Registering the patient and directing the patient to the service area In addition to being supported by information found in the patient's chart, a CMS 1500 claim must be coded using what? CRCR Exam Latest HCPCS (Healthcare Common Procedure Coding system) What results from a denied claim? The provider incurs rework and appeal costs Why does the financial counselor need pricing for services? To calculate the patient's financial responsibility What type of provider bills third-party payers using CMS 1500 form Hospital-based mammography centers How are disputes with nongovernmental payers resolved? Appeal conditions specified in the individual payer's contract The important message from Medicare provides beneficiaries with information concerning what? Right to appeal a discharge decision if the patient disagrees with the services Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? To improve access to quality healthcare CRCR Exam Latest Blue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? It is acceptable to complete the screening form after the patient has completed the registration process and been sent to the service department If the patient cannot agree to payment arrangements, what is the next option? Warn the patient that unpaid accounts are placed with collection agencies for further processing In services lines such as cardiology or orthopedics, what does the case-rate payment methodology allow providers to do? Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? Code of conduct How does utilization review staff use correct insurance information? To obtain approval for inpatient days and coordinate services CRCR Exam Latest When is it not appropriate to use observation status? As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? The services will be documented in the wrong record When a patient reports directly to a clinical department for service, what will the clinical department staff do? Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail How are patient reminder calls used? To make sure the patient follows the prep instructions and arrives at the scheduled time for service If a patient declares a straight bankruptcy, what must the provider do? Write off the account to the contractual adjustment account According to the Department of Health and Human Services guidelines, what is NOT considered income? Sale of property, house, or car CRCR Exam Latest The situation where neither the patient nor spouse is employed is described to the patient using: A condition code What option is an alternative to valid long-term payment plans? Bank loans What is an advantage of using a collection agency to collect delinquent patient accounts? Collection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? revenue codes identify the payer When a patient's illness results in an unusually high amount of medical bills not covered by insurance or other patient pay resources, what type of account is created catastrophic charity What happens when a patient receives non-emergent services from and out-of-network provider? Patient payment responsibility is higher Every patient who is new to the healthcare provider must be offered what? A printed copy of the provider's privacy notice CRCR Exam Latest APC rates are calculated on a national basis and are wage-adjusted by geographic region What is a benefit of insurance verification? Pre-certification or pre-authorization requirements are confirmed What is an effective tool to help staff collect payments at the time of service? Develop scripts for the process of requesting payments What is a benefit of electronic claims processing? Providers can electronically view patient's eligibility What does Medicare Part D provide coverage for? Prescription drugs What are some core elements of a board-approved financial policy Charity care, payment methods, and installment payment guidelines What circumstance would result in an incorrect nightly room charge? If the patient's discharge, ordered for tomorrow, has not been charted What is NOT a typical charge master problem that can result in a denial? Does not include required modifiers CRCR Exam Latest Access An individual's ability to obtain medical services on a timely and financially acceptable level Administrative Services Only (ASO) Usually contracted administrative services to a self-insured health plan Case management The process whereby all health-related components of a case are managed by a designated health professional. Intended to ensure continuity of healthcare accessibility and services Claim A demand by an insured person for the benefits provided by the group contract Coordination of benefits (COB) a typical insurance provision that determines the responsibility for primary payment when the patient is covered by more than one employer-sponsored health benefit program Discounted fee-for-service A reimbursement methodology whereby a provider agrees to provide service on a fee for service basis, but the fees are discounted by certain packages Eligibility CRCR Exam Latest Patient status regarding coverage for healthcare insurance benefits First dollar coverage A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses Gatekeeping A concept wherein the primary care physician provides all primary patient care and coordinates all diagnostic testing and specialty referrals required for a patient's medical care Health plan an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary Healthcare services that are required to preserve or maintain a person's health status in accordance with medical practice standards Out-of-area benefits healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO CRCR Exam Latest The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Cost The definition of cost varies by party incurring the expense Price the total amount a provider expects to be paid by payers and patients for healthcare services Care purchaser Individual or entity that contributes to the purchase of healthcare services Payer An organization that negotiates or sets rates for provider services, collects revenue through premium payments or tax dollars, processes provider claims for service, and pays provider claims using collected premium or tax revenues Provider An entity, organization, or individual that furnishes a healthcare service Out of pocket payment The portion of the total payment for medical services and treatment for which the patient is responsible, including copayments, coinsurance, and deductibles CRCR Exam Latest Price transparency In health care, readily available information on the price of healthcare services that, together, with other information helps define the value of those services and enables patients and other care purchasers to identify, compare, and choose providers that offer the desired level of value Value The quality of a healthcare service in relation to the total price paid for the service by care purchasers What areas does the code of conduct typically focus on? Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations FERA Fraud Enforcement and Recovery act ESRD End-stage renal disease. The patient has permanent kidney failure, is covered by a GHP, and has not yet completed the 30-month coordination period What is the purpose of a compliance program? Mitigate potential fraud and abuse in the industry-specific key risk areas What is important about an effective corporate compliance program? CRCR Exam Latest A program that embodies many elements to create a program that is transparent, clearly articulated and emphasized at all employee levels as a seriously held personal and organizational responsibility, one that relies on full communication inside and outside the organization What is a CCO Chief compliance officer - they typically report directly to the board of directors/trustees as well as the chief executive officer, and has limited responsibilities for other operational aspects of the organization What are the situations where another payer may be completely responsible for payment? Work-related accidents, black lung program services, patient is enrolled in Medicare Advantage, Federal grant programs Under Medicare rules, certain outpatient services that are provided within three days of the admission date, by hospitals or by entities owned or controlled by hospitals, must be billed as part of an inpatient stay. TRUE The OIG has issued compliance guidance/model compliance plans for all of the following entities: hospices. physician practices. ambulance providers Providers who are found to be in violation of CMS regulations are subject to: Corporate integrity agreements What MSP situation requires LGHP Disability