CRCR Exam Prep Questions and Answers 2024/2025, Exams of Nursing

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correct answers 2024\2025.

What are collection agency fees based on? - Answer A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - Answer Birthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - Answer Case rates What customer service improvements might improve the patient accounts department? - Answer Holding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - Answer Inform a Medicare beneficiary that Medicare may not pay for the order or service

correct answers 2024\2025.

What type of account adjustment results from the patient's unwillingness to pay for a self-pay balance? - Answer Bad debt adjustment What is the initial hospice benefit? - Answer Two 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - Answer 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? - Answer 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 - Answer They are not being processed in a timely manner

correct answers 2024\2025.

What is an advantage of a preregistration program? - Answer It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - Answer Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - Answer Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts What statement applies to the scheduled outpatient? - Answer The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - Answer Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount

correct answers 2024\2025.

What type of patient status is used to evaluate the patient's need for inpatient care? - Answer Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - Answer Medically necessary inpatient hospital services for at least 3 consecutive days before the skilled nursing care admission When is the word "SAME" entered on the CMS 1500 billing form in Field 0$? - Answer When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - Answer Unscheduled patients If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - Answer Neither enrolled not entitled to benefits

correct answers 2024\2025.

Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what? - Answer Disclosure rules for consumer credit sales and consumer loans What is a principal diagnosis? - Answer Primary reason for the patient's admission Collecting patient liability dollars after service leads to what? - Answer Lower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - Answer 50% of the current deductible amount What service provided to a Medicare beneficiary in a rural health clinic (RHC) is not billable as an RHC services? - Answer Inpatient care What code indicates the disposition of the patient at the conclusion of service? - Answer Patient discharge status code

correct answers 2024\2025.

What are hospitals required to do for Medicare credit balance accounts? - Answer 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? - Answer Patient Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: - Answer A valid CPT or HCPCS code With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what? - Answer Access their information and perform functions on-line

correct answers 2024\2025.

What date is required on all CMS 1500 claim forms? - Answer onset date of current illness What does scheduling allow provider staff to do - Answer Review appropriateness of the service request What code is used to report the provider's most common semiprivate room rate? - Answer Condition code Regulations and requirements for coding accountable care organizations, which allows providers to begin creating these organizations, were finalized in: - Answer 2012 What is a primary responsibility of the Recover Audit Contractor? - Answer To correctly identify proper payments for Medicare Part A & B claims

correct answers 2024\2025.

How must providers handle credit balances? - Answer Comply with state statutes concerning reporting credit balance Insurance verification results in what? - Answer The accurate identification of the patient's eligibility and benefits What form is used to bill Medicare for rural health clinics? - Answer CMS 1500 What activities are completed when a scheduled pre-registered patient arrives for service? - Answer 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? - Answer HCPCS (Healthcare Common Procedure Coding system)

correct answers 2024\2025.

What results from a denied claim? - Answer The provider incurs rework and appeal costs Why does the financial counselor need pricing for services? - Answer To calculate the patient's financial responsibility What type of provider bills third-party payers using CMS 1500 form - Answer Hospital-based mammography centers How are disputes with nongovernmental payers resolved? - Answer Appeal conditions specified in the individual payer's contract The important message from Medicare provides beneficiaries with information concerning what? - Answer Right to appeal a discharge decision if the patient disagrees with the services

correct answers 2024\2025.

Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - Answer To improve access to quality healthcare If a patient remains an inpatient of an SNF (skilled nursing facility for more than 30 days, what is the SNF permitted to do? - Answer Submit interim bills to the Medicare program.

90. MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - Answer 120 days passes, but the claim then be withdrawn from the liability carrier What data are required to establish a new MPI entry? - Answer The patient's full legal name, date of birth, and sex What should the provider do if both of the patient's insurance plans pay as primary? - Answer Determine the correct payer and notify the incorrect payer of the processing error

correct answers 2024\2025.

What do EMTALA regulations require on-call physicians to do? - Answer Personally appear in the emergency department and attend to the patient within a reasonable time At the end of each shift, what must happen to cash, checks, and credit card transaction documents? - Answer They must be balanced What will cause a CMS 1500 claim to be rejected? - Answer The provider is billing with a future date of service Under Medicare regulations, which of the following is not included on a valid physician's order for services? - Answer The cost of the test how are HCPCS codes and the appropriate modifiers used? - Answer To report the level 1, 2, or 3 code that correctly describes the service provided

correct answers 2024\2025.

If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - Answer Diagnostic and clinically-related non-diagnostic charges provided on the Tuesday, Wednesday, Thursday, and Friday before admission What is a benefit of pre-registering patient's for service? - Answer Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - Answer Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - Answer That the patient's spouse's employer must have less than 20 employees in the group health plan what organization originated the concept of insuring prepaid health care services? - Answer Blue Cross and blue Shield

correct answers 2024\2025.

What is true about screening a beneficiary for possible MSP situations?

• Answer 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? - Answer 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? - Answer Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? - Answer Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - Answer Code of conduct

correct answers 2024\2025.

How does utilization review staff use correct insurance information? - Answer To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - Answer As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - Answer 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? - Answer Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - Answer Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail

correct answers 2024\2025.

How are patient reminder calls used? - Answer 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? - Answer Write off the account to the contractual adjustment account According to the Department of Health and Human Services guidelines, what is NOT considered income? - Answer Sale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - Answer A condition code What option is an alternative to valid long-term payment plans? - Answer Bank loans

correct answers 2024\2025.

What is an advantage of using a collection agency to collect delinquent patient accounts? - Answer Collection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? - Answer 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 - Answer catastrophic charity What happens when a patient receives non-emergent services from and out-of-network provider? - Answer Patient payment responsibility is higher Every patient who is new to the healthcare provider must be offered what? - Answer A printed copy of the provider's privacy notice

correct answers 2024\2025.

How may a collection agency demonstrate its performance? - Answer Calculate the rate of recovery What is true of the information the provider supplies to indicate that an authorization for service has been received from the patient's primary payer? - Answer It is posted on the remittance advice by the payer What standard claim forms are currently used by the healthcare industry to submit claims to third-party payers? - Answer The UB- and the CMS 1500 Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information? - Answer Obtain the required demographic and insurance information before services are rendered what protocol was developed through the Patient Friendly Billing Project? - Answer Provide information using language that is easily understood by the average reader

correct answers 2024\2025.

What technique is acceptable way to complete the MSP screening for a facility situation? - Answer Ask if the patient's current services was accident related What is a valid reason for a payer to delay a claim? - Answer Failure to complete authorization requirements IF outpatient diagnostic services are provided within three days of the admission of a Medicare beneficiary to an IPPS (Inpatient Prospective Payment System) hospital, what must happen to these charges - Answer They must be combined with the inpatient bill and paid under the MS-DRG system What do large adjustments require? - Answer Manager-level approval What items are valid identifiers to establish a patient's identification? - Answer Photo identification, date of birth, and social security number

correct answers 2024\2025.

What must a provider do to qualify an account as a Medicare bad debts? - Answer Pursue the account for 120 days and then refer it to an outside collection agency What restriction does a managed care plan place on locations that must be used if the plan is to pay for the services provided? - Answer Site-of- service limitation What is an example of an outcome of the Patient Friendly Billing Project? - Answer Redesigned patient billing statements using patient- friendly language What statement describes the APC (Ambulatory payment classification) system? - Answer APC rates are calculated on a national basis and are wage-adjusted by geographic region

correct answers 2024\2025.

What is a benefit of insurance verification? - Answer Pre-certification or pre-authorization requirements are confirmed What is an effective tool to help staff collect payments at the time of service? - Answer Develop scripts for the process of requesting payments What is a benefit of electronic claims processing? - Answer Providers can electronically view patient's eligibility What does Medicare Part D provide coverage for? - Answer Prescription drugs What are some core elements of a board-approved financial policy - Answer Charity care, payment methods, and installment payment guidelines

correct answers 2024\2025.

What circumstance would result in an incorrect nightly room charge? - Answer 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? - Answer Does not include required modifiers Access - Answer An individual's ability to obtain medical services on a timely and financially acceptable level Administrative Services Only (ASO) - Answer Usually contracted administrative services to a self-insured health plan Case management - Answer 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

correct answers 2024\2025.

Claim - Answer A demand by an insured person for the benefits provided by the group contract Coordination of benefits (COB) - Answer 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 - Answer 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 - Answer Patient status regarding coverage for healthcare insurance benefits First dollar coverage - Answer A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses

correct answers 2024\2025.

Gatekeeping - Answer 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 - Answer an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - Answer negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary - Answer Healthcare services that are required to preserve or maintain a person's health status in accordance with medical practice standards Out-of-area benefits - Answer healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO

correct answers 2024\2025.

Out-of-pocket payments - Answer Cash payments made by the insured for services not covered by the health insurance plan Pre-admission review - Answer the practice of reviewing requests for inpatient admission before the patient is admitted to ensure that the admission is medically necesary Pre-existing condition limitation - Answer A restriction on payments for charges directly resulting from a pre-existing health conditions Same-day admission - Answer A cost containment practice that reduces a surgical patient's inpatient stay by requiring that pre-procedure testing and preparation are completed on an outpatient basis and the patient is admitted the same day as the procedure

correct answers 2024\2025.

Self-insured - Answer Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Subrogation - Answer Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses Subscriber - Answer An employer, a union, or an association that contracts with an insurance company for the healthcare plan it offers to eligible employees Sub-specialist - Answer A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery Third-part administrator (TPA) - Answer Provides services to employers or insurance companies for utilization review, claims payment and benefit design