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A collection of multiple-choice questions and answers designed to prepare individuals for the certified revenue cycle representative (crcr) exam. It covers various aspects of healthcare revenue cycle management, including medicare secondary payer (msp) rules, compliance programs, patient identification, and billing procedures. The questions and answers offer insights into key concepts and regulations relevant to the crcr exam.
Typology: Exams
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[Date] a) The health plan cannot identify the subscriber b) The frequency of service was outside the coverage timeline c) The submitted claim does not have the physicians signature d) The subscriber was not enrolled at the time of service โ ANS C A comprehensive "Compliance Program" is defined as a) Annual legal audit and review for adherence to regulations b) Educating staff on regulations c) Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met d) The development of operational policies that correspond to regulations โ ANS C A decision on whether a patient should be admitted as an inpatient or become an outpatient observation patient requires medical judgments based on all of the following EXCEPT a) The patient's home care coverage b) Current medical needs c) The likelihood of an adverse event occurring to the patient d) The patient's medical history โ ANS A
[Date] A four digit number code established by the National Uniform Billing Committee (NUBC) that categorizes/classifies a line item in the charge master is known as a) HCPCs codes b) ICD-10 Procedural codes c) CPT codes d) Revenue codes โ ANS D A large number of credit balances are not the result of overpayments but of a) Posting errors in the pt accounting system b) Incorrect claim submissions c) Inadequate staff training d) Banking transaction errors โ ANS A A Medicare Part A benefit period begins: a) With admission as an inpatient b) The first day in which an individual has not been a hospital inpatient not in a skilled nursing facility for the previous 60 days
[Date] c) Upon the day the coverage premium is paid d) Immediately once authorization for treatment is provided by the health plan โ ANS A A nightly room charge will be incorrect if the patient's a) Discharge for the next day has not been charted b) Condition has not been discussed during the shift change report meeting c) Pharmacy orders to the ICU have not been entered in the pharmacy system d) Transfer from ICU (intensive care unit) to the Medical/Surgical floor is not reflected in the registration system โ ANS D A portion of the accounts receivable inventory which has NOT qualified for billing includes a) Charitable pledges b) Accounts assigned to a pre-collection agency c) Accounts coded but held within the suspense period d) Accounts created during pre-registration but not activated โ ANS A
[Date] A portion of the accounts receivable inventory which has NOT qualified for billing includes: a) Charitable pledges b) Accounts created during pre-registration but not activated c) Accounts coded but held within the suspense period d) Accounts assigned to a pre-collection agency - ANSA A recurring/series registration is characterized by a) A creation of multiple registrations for multiple services b) The creation of one registration record for multiple days of service c) The creation of multiple patient types for one date of service d) The creation of one registration record per diagnosis per visit โ ANS B A recurring/series registration is characterized by a) The creation of one registration record for multiple days of service b) The creation of multiple registrations for multiple services c) The creation of one registration record per diagnosis per visits d) The creation of multiple pt types for one date of service โ ANS A
[Date] A scheduled inpatient represents an opportunity for the provider to do which of the following? a) Refer the patient to another location with the health system b) Comply with EMTALA (Emergency Medical Treatment and Labor Act) requirements before service c) Complete registration and insurance approval before service d) Register the patient after he or she is placed in a bed on that service unit. โ ANS C ABC Hospital has experienced a 16% increase in new patients over the past 6 months. The hospital is understaffed in its insurance claim and payment processing department and cannot handle this increase in work load. It is considering hiring an outsourcing vendor to assist. What are the steps that the hospital needs to take to establish and ensure a successful vendor relationship? โ ANS A. Distribute a RFP to solicit vendor capabilities, evaluate vendor's expertise to provide outsourcing services, visit vendor locations, perform vendor reference checks, talk with vendor clients, interview vendor employees to assess experience level.
[Date] B. Evaluate vendor's expertise in providing outsourcing services, visit vendor locations, interview vendor employees to assess expertise level. Access โ ANS An individual's ability to obtain medical services on a timely and financially acceptable level Access โ ANS An individual's ability to obtain medical services on a timely and financially acceptable level According to the Department of Health and Human Services guidelines, what is NOT considered income? โ ANS Sale of property, house, or car According to the Department of Health and Human Services guidelines, what is NOT considered income? โ ANS Sale of property, house, or car Accurate identification of the patient is the first step in the scheduling process. Identifiers used in various combination to achieve accurate patient identification include? โ ANS Full legal name, date of birth, sex and social security number Across all care settings, if a patient consents to a financial discussion during a medical encounter to expedite discharge, the HFMA best practice is to: a) Make sure that the attending staff can answer questions and assist in obtaining required patient financial data
[Date] b) Have a patient financial responsibilities kit ready for the patient, containing all of the required registration forms and instructions c) Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow d) Decline such request as finance discussions can disrupt patient care and patient flow โ ANS C Across all care settings, if a pt consents to a financial discussion during a medical encounter to expedite discharge, the HFMA best practice is to a) Have a pt financial responsibilities kit ready for the pt containing all of the required registration forms and instructions b) Make sure that the attending staff can answer questions and assist in obtaining required pt financial data c) Support that choice, providing that the discussion does not interfere with pt care or disrupt pt flow d) Decline such request as finance discussions can disrupt pt care and pt flow โ ANS C Administrative Services Only (ASO) โ ANS Usually contracted administrative services to a self-insured health plan
[Date] Administrative Services Only (ASO) โ ANS Usually contracted administrative services to a self-insured health plan Agency fees are: - ANS A. Paid by patients. ** B. The cost to the provider for collection agency monies offset by the return on baddebt accounts. C. Only reported annually to the provider. D. Waived for accounts aged greater than one year from date of service. All of the following are conditions that disqualify a procedure or service from being paid for by Medicare EXCEPT a) Medically unnecessary b) Not delivered in a Medicare licensed care setting c) Offered in an outpatient setting d) Services and procedures that are custodial in nature โ ANS D All of the following are forms of hospital payment contracting EXCEPT a) Contracted Rebating b) Per Diem Payment c) Fixed Contracting
[Date] d) Bundled Payment โ ANS A All of the following are forms of hospital payment contracting EXCEPT a) Per diem payment b) Bundled Payment c) Fixed Contracting d) Contracted Rebating - ANSD All of the following are potential causes of credit balances EXCEPT a) Duplicate payments b) Primary and secondary payers both paying as primary c) Inaccurate upfront collections based on incorrect liability estimates d) A patient's choice to build up a credit against future medical bills - ANSD All of the following are steps in safeguarding collections EXCEPT a) Placing collections in a lock-box for posting review the next business day b) Posting the payment to the pts account c) Completing balance activities d) Issuing receipts - ANSD
[Date] All of the following information should be reviewed as part of schedule finalization EXCEPT: a) The results of any and all test b) The service to be provided c) The arrival time and procedure time d) The patient's preparation instructions - ANSA Ambulance services are billed directly to the health plan for a) All pre- admission emergency transports b) Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility c) The portion of the bill outside of the patient's self-pay d) Transports deemed medically necessary by the attending paramedic-ambulance crew โ ANSC Ambulance services are billed directly to the health plan for a) All pre- admission emergency transports b) Transport deemed medically necessary by the attending paramedic-ambulance crew c) Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility d) The portion of the bill outside of the patient's self-pay - ANSC
[Date] An advantage of a pre-registration program is a) The opportunity to reduce processing times at the time of service b) The ability to eliminate no-show appointments c) The opportunity to reduce the corporate compliance failures within the registration process d) The marketing value of such a program - ANSC an increase in the dollars aged greater than 90 days from date of service indicate what about accounts - ANSThey are not being processed in a timely manner an increase in the dollars aged greater than 90 days from date of service indicate what about accounts - ANSThey are not being processed in a timely manner An individual enrolled in Medicare who is dissatisfied with the government's claim determination is entitled to reconsideration of the decision. This type of appeal is known as a) A beneficiary appeal b) A Medicare supplemental review c) A payment review d) A Medicare determination appeal - ANSA An individual enrolled in Medicare who is dissatisfied with the government's claim determination is entitled to reconsideration of the
[Date] decision. This type of appeal is known as a) A medicare determination appeal b) A payment review c) A medicare supplemental review d) A beneficiary appeal - ANSD An originating site is a) The location where the pts bill is generated b) The location of the pt at the time the service is provided c) The site that generates reimbursement of a claim d) The location of the medical treatment provider - ANSB Annually, the OIG publishes a work plan of compliance issues and objectives that will be focused on throughout the following year. Identify which option is NOT a work plan task mentioned in this course. - ANSA. Payments to Physicians for Co-Surgery Procedures B. Denials and Appeals in Medicare Part D C. Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute-Care Transfer Policies **D. Standard Unique Employer Identifier Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons based on; a monthly fee is known as a a) HMO b) PPO c) MSO d) GPO - ANSA Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons based on a monthly fee is known as a a) MSO
[Date] b) HMO c) PPO d) GPO - ANSB Any provider that has filed a timely cost report may appeal an adverse final decision received from the Medicare Administrative Contractor (MAC). This appeal may be filed with a) A court appointed federal mediator b) The Department of Health and Human Services Provider Relations Division c) The Office of the Inspector General d) The Provider Reimbursement Review Board - ANSD Appropriate training for patient financial counseling staff must cover all of the following EXCEPT: a) Patient financial communications best practices specific to staff role b) Financial assistance policies c) Documenting the conversation in the medical records d) Available patient financing options - ANSC At the end of each shift, what must happen to cash, checks, and credit card transaction documents? - ANSThey must be balanced At the end of each shift, what must happen to cash, checks, and credit card transaction documents? - ANSThey must be balanced Based on what you have just read, which activity is not considered when initiating self-pay follow-up and account resolution activities? - ANSA. Poverty Guidelines B. Financial Profile C. Presumptive Financial Assistance Determination **D. Patient Open Balance Billing Because 501(r) regulations focus on identifying potential eligible financial assistants patients hospitals must: a) Capture their experience
[Date] with such patients to properly budget b) Hold financial conversations with patients as soon as possible c) Build the necessary processes to handle the potentially lengthy payment schedule d) Expedite payment processing of normal accounts receivable to protect cash flow - ANSB Before classifying and subsequently writing off an account to financial assistance or bad debt, the hospital must establish policy, define appropriate criteria, implement procedures for identifying and processing accounts: a) Monitor compliance b) Have the account triaged for any partial payment possibilities c) Assist in arranging for a commercial bank loan d) Obtain the patients income tax statements from the prior 2 years - ANSA Business ethics, or organizational ethics represent: a) The principles and standards by which organizations operate b) Regulations that must be followed by law c) Definitions of appropriate customer service d) The code of acceptable conduct - ANSA Care purchaser - ANSIndividual or entity that contributes to the purchase of healthcare services Care purchaser - ANSIndividual or entity that contributes to the purchase of healthcare services Case management - ANSThe 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 Case
[Date] management - ANSThe 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 Case management and discharge planning services are a post-service activty - ANSTrue **False Case Management requires that a case manager be assigned a) To patients of any physician requesting case management b) To a select patient group c) To every patient d) To specific cases designated by third party contractual agreement - ANSB Case managers are involved from admission with the discharge planning process. The purpose of discharge planning is: - ANSTo estimate how long the patient will be in the hospital, identify the expected outcome of the hospitalization and initiate any special requirements for services at or after the time of discharge. Chapter 13 Bankruptcy, debtor rehabilitation is a court proceeding a) That reorganizes a debtor's holdings and instructs creditors to look to the debtors' future earnings for payment b) That establishes a payment priority order to creditos' c) That creates a clear court-supervised payment accountability plan going forward d) That classifies the debtor as eligible for government financial assistance for housing medical treatment and food as debts are paid - ANSA Chapter 13 Bankruptcy, debtor rehabilitation, is a court proceeding a)
[Date] That establishes a payment priority order to creditors' claims b) That classifies the debtor as eligible for government financial assistance for housing, medical treatment and food as debts are paid c) That creates a clear court-supervised payment accountability plan going forward d) That reorganizes a debtor's holdings and instructs creditors to look to the debtor's future earnings for payment - ANSD Charge - ANSThe dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Charge - ANSThe dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Charges are the basis for a) Third party and regulatory review of resources used b) Evaluating quality c) Separation of fiscal responsibilities between the pt and the health plan d) Demonstrating medical necessity - ANSC Charges as the most appropriate measurement of utilization enables a) Accuracy of expense and cost capture b) Managing of expense budgets c) Effective HIM planning d) Generation of timely and accurate billing - ANSA Charges, as the most appropriate measurement of utilization, enables a) Generation of timely and accurate billing b) Managing of expense budgets c) Accuracy of expense and cost capture d) Effective HIM planning - ANS???Number 24???
[Date] Checks received through mail, cash received through mail, and lock box are all examples of a) Highly fraud prone processes b) Payment methods in which the majority of fraud occurs c) Payment methods being phased out for more secure payment method options d) Control points for cash posting - ANSD Claim - ANSA demand by an insured person for the benefits provided by the group contract Claim - ANSA demand by an insured person for the benefits provided by the group contract Claims with dates of service received later than one calendar year beyond the date of service, will be a) Denied by Medicare b) The provider's responsibility but can be deemed charity care c) Fully paid with interest d) The full responsibility of the patient. - ANSA Collecting patient liability dollars after service leads to what? - ANSLower accounts receivable levels Collecting patient liability dollars after service leads to what? - ANSLower accounts receivable levels Collection agency reports should be provided: - ANSA. Whenever staff have the time to generate them. B. Whenever an account is cancelled. **C. In at least two formats regarding accounts assigned on a routine basis. D. As needed to prove recovery rates. Collection results are: - ANSA. Always guaranteed by the collection agency. **B. Accurately calculated to demonstrate the actual recovery percentage rate. C. Calculated using agency's private formula. D. Never
[Date] reported except during contract negotiations. Concurrent review and discharge planning a) Occurs during service b) Is performed by the health plan during the time of service c) Is a significant part of quality and is performed by the clinical treatment team d) Is performed at discharge with the pt - ANSA Consents are signed as part of the post- services process. - ANSTrue **False Coordination of benefits (COB) - ANSa typical insurance provision that determines the responsibility for primary payment when the patient is covered by more than one employer-sponsored health benefit program Coordination of benefits (COB) - ANSa typical insurance provision that determines the responsibility for primary payment when the patient is covered by more than one employer-sponsored health benefit program Corporate compliance programs play an important role in protecting the integrity of operations and ensuring compliance with federal and state requirements. The code of conduct is: - ANSAll of the above Cost - ANSThe definition of cost varies by party incurring the expense Cost - ANSThe definition of cost varies by party incurring the expense Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - ANSMedically necessary inpatient hospital services for at least 3 consecutive days before the
[Date] skilled nursing care admission Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - ANSMedically necessary inpatient hospital services for at least 3 consecutive days before the skilled nursing care admission Credit balances may be created by any of the following activities except: - ANSCredits to pharmacy charges posted before the claim final bills Days in A/R is calculated based on the value of a) Total cash received to date b) The time it takes to collect anticipated revenue c) The total accounts receivable on a specific date d) Total anticipated revenue minus expenses - ANSC Days in A/R is calculated based on the value of: a) The total accounts receivable on a specific date b) Total anticipated revenue minus expenses c) The time it takes to collect anticipated revenue d) Total cash received to date - ANSC Discounted fee-for-service - ANSA reimbursement methodology whereby a provider agrees to provide service on a fee for service basis, but the fees are discounted by certain packages Discounted fee-for-service - ANSA reimbursement methodology whereby a provider agrees to provide service on a fee for service basis, but the fees are discounted by certain packages DRG's are a system of classifying inpatients on the basis of diagnoses, procedures, and co-morbidities for purposes of payment to hospitals. Each DRG
[Date] includes: - ANSA relative weight which is multiplied by the established base payment rate to calculate the reimbursement for a specific DRG. For exceptionally costly cases over a set dollar amount, an outlier payment is added to the calculated payment. Duplicate payments occur: a) When providers re-bill claims based on nonpayment from the initial bill submission b) When service departments do not process charges with the organization's suspense days c) When the payer's coordination of benefits is not captured correctly at the time of patient registration d) When there are other healthcare claims in process and the anticipated deductibles and co-insurance amounts still show open but will be met by the in-process claims - ANSa Each hospital covered by the 501(r) regulations is required to develop a financial assistance policy. Which of the following elements is NOT a required element of the policy? - ANSThe notice that individuals eligible for financial assistance under this policy may be charged more that the amount generally billed (AGB) to insured patients. Each type of service has unique billing rules which come into play during the provision of service. For the skilled nursing facility, care is covered if which of the following factors are present: - ANSThe patient required skilled services on a daily basis and those services can only be provided on an inpatient basis in a SNF. EFT
[Date] (electronic funds transfer) is a) An electronic claim submission b) The record of payments in the hospital's accounting system c) An electronic confirmation that a payment is due d) An electronic transfer of funds from payer to payee - ANSD Eligibility - ANSPatient status regarding coverage for healthcare insurance benefits Eligibility - ANSPatient status regarding coverage for healthcare insurance benefits EMTALA prohibits inquiries about health plan or liability payer information if the inquiry will delay examination or treatment. What other requirements apply to the Emergency Department registration work? - ANSALL of the above ESRD - ANSEnd-stage renal disease. The patient has permanent kidney failure, is covered by a GHP, and has not yet completed the 30-month coordination period ESRD - ANSEnd-stage renal disease. The patient has permanent kidney failure, is covered by a GHP, and has not yet completed the 30-month coordination period Every patient who is new to the healthcare provider must be offered what? - ANSA printed copy of the provider's privacy notice Every patient who is new to the healthcare provider must be offered what? - ANSA printed copy of the provider's privacy notice Examples of managed care plans include: - ANSAll of the above FERA - ANSFraud Enforcement and Recovery act FERA - ANSFraud Enforcement and Recovery act First dollar coverage - ANSA healthcare
[Date] insurance policy that has no deductible and covers the first dollar of an insured's expenses First dollar coverage - ANSA healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions: a) Are optional b) Should take place between the patient or guarantor and properly trained provider representatives c) May take place between the patient and discharge planning d) Are focused on verifying required third-party payer information - ANSB For scheduled patients, important revenue cycle activities I the Time of Service stage DO NOT INCLUDE: a) Pre- registration record is activated, consents are signed, and co-payment is collected b) Positive patient identification is completed, and patient is given an armband c) Final bill is presented for payment d) Preprocessed patients may report to a designated "express arrival" desk - ANSC Gatekeeping - ANSA 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 Gatekeeping
[Date] company that provides for the delivery or payment of healthcare services Health plan - ANSan insurance company that provides for the delivery or payment of healthcare services Health Plan Contracting Departments do all of the following EXCEPT a) Establish a global reimbursement rate to use with all third-party payer b) Review all managed care contracts for accuracy for loading contract terms into the patient accounting system c) Review payment schemes to ensure that the health plan and provider understand how reimbursements must be calculated d) Review contracts to ensure the appeals process for denied claims is clearly specified - ANSA HFMA best practices call for patient financial discussions to be reinforced a) By issuing a new invoice to the patient b) By copying the provider's attorney on a written statement of conversation c) By obtaining some type of collateral d) By changing policies to programs - ANSB HFMA best practices stipulate that a reasonable attempt should be made to have the financial responsibilities discussion a) As early as possible, before a financial obligation is incurred b) During the registration process c) Before scheduling of services d) No later than the evening of the day of admission - ANSA HFMA's patient financial communication best practices specify that patients should be told about the types of services provided and a) A satisfaction survey
[Date] regarding clinical service providers b) The price of service to their covering health plan c) The service providers that typically participate in the service, e.g., radiologists, pathologists, etc. d) An expiration of why a specific service is not provided - ANSC HFMA's pt financial communications best practices specify that pts should be told about the types of services provided and a) An explanation of why a specific service is not provided b) The service providers that typically participate in the service, e.g.radiologists, pathologists, etc. c) A satisfaction survey regarding clinical service providers d) The price of service to their covering health plan - ANSB HIPPA had adopted Employer Identification Numbers (EIN) to be used in standard transactions to identify the employer of an individual described in a transaction EIN's are assigned by a) The Social Security Administration b) The US department of the Treasury c) The United States department of labor d) The Internal Revenue Service - ANSD Historically, revenue cycle has delt with contractual adjustments, bad debt and charity deductions from gross revenue. Although deductions continue to exist, the definition of net revenue has been modified through the implementation of ASC 606. Developed by the Financial Accounting Standards Board (FASB), this change became effective in 2018. What is the new terminology now