CRCR Final Exam Questions with Complete Solutions, Exams of Law

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CRCR Final Exam Questions with

Complete Solutions

What do Case Managers do? - ANS: Monitor high resource cases to ensure effective utilization What is HIM responsible for? - ANS: all pt medical records: transcribe, coding, release to biling, answer requests for documentation What is utilization management responsible for? - ANS: manage cases: services correct, on time What are the three types of utilization review? - ANS: Prospective, Concurrent, Retrospective Where can home health services be offered? - ANS: Home, Assist Living, neighbors: just not SNF nor Hospital To receive -Care payments, what must a SNF have when receiving a pt from a hosp? - ANS: A transfer agreement approved by -Care. Can a home health agency employ another agency to provide services? - ANS: Yes, so long as at least one employee of the original agency provides care. What is the Net Collection Rate? - ANS: how much cash was collected as a % of available to collect? What is the Net Collection Rate benchmark? - ANS: 95% What is the benchmark for denials - ANS: <2% on first submission Formual for cost to collect - ANS: total PFS expenses/gross pt care collections What is the benchmark for cost to collect - ANS: 2.25%

What % of the UB-04 source of data is from pt access? - ANS: 40% What % of the UB-04 source of data is from service depts? - ANS: 11% What % of the UB-04 source of data is from HIM? - ANS: 20% What % of the UB-04 source of data is from billing? - ANS: 20% What % of the UB-04 source of data is not used? - ANS: 9% What % of the CMS 1500 source of data is from pt access? - ANS: 53% What % of the CMS 1500 source of data is from service? - ANS: 14% What % of the CMS 1500 source of data is from HIM - ANS: 7% What % of the CMS 1500 source of data is from billing? - ANS: 26% From whom is the UB-04 directed? - ANS: institutional: hospitals, SNF, hospice From whom is the CMS 1500? - ANS: non-institutional: physicians, DME In the FDCA, what is Title I - ANS: Truth in Lending Act What is the Truth in Lending Act - ANS: 5 points must be triggered (such as interest will be charged), then must disclose APR, total payments, late payment charges, etc. What are the penalties for violating the FDCA? - ANS: creditors can be sued

Who enforces the FDCA for hospitals? - ANS: FTC In the FDCA, what is Title III - ANS: limits garnishments In the FDCA, what is Title IV - ANS: Fair Credit Reporting Act What is the Fair Credit Reporting Act? - ANS: provides consumer rights in reporting loans Are there rules for how a debt collector communicates with debtor? - ANS: Yes, eg no profane language, can't contact before 8 AM Is a newborn a scheduled or unscheduled pt - ANS: unscheduled What are the three types of pt access incoming to a HCO? - ANS: scheduled, unscheduled, recurring What is LCD - ANS: local coverage determinants, in absence of NCD, LCD dtermines whether -Care will pay for an item or service What is NCD - ANS: national coverage determinants:' nationwide determination of whether Medicare will pay for an item or service What % of pts should be pre-registered of all scheduled pts? - ANS: 98% What is the code for HIPAA transaction set for HC eligibility and benefit responses - ANS: 270 outgoing 271 response What are some payer data elements needed to process payment? - ANS: policy type, covered persons, mail address, cvr type (HMO), deductible

What is an PPO - ANS: closest to indemnity plan, only preferred doctors in network get contracted prices What is an EPO - ANS: exclusive provider - limits services to only EP What is POS - ANS: point of service - if doc makes referral out, plan will pay, if pt requests out of service, pt pays What is CDHP - ANS: consumer directed healthplan, often with a HSA What is the % discount model in MCO - ANS: a % is discounted What is the DRG model in MCO - ANS: pymt based on predetermined fixed amount What is the APG model in MCO - ANS: divides outpt services into 600 procedural groups, each APG assigned a relative payment weight What is a case rate - ANS: pt's condition forms basis for payment for all services What is stop loss - ANS: plan covers 80% of charges to 100%, stop loss is plan covers 50% of charges

$120k What are some managed care requirments? - ANS: pre-certification/pre-authorization, referral (PCP- specialist), notification - providers notify payer pt is requesting service, days approval, continued stay review, site of service limitations (eg only colonosco as outpt) What are some concerns with EMTALA - ANS: sign posted on walls, no prior authorization, women in active labor must be assisted thru delivery, on-call MD must respond, no dumping, no transfer (unless cannot provide service), must do mental health screening, must keep pt log What is the referring MD - ANS: the one to referred to another MD

What is the attending MD - ANS: One who wrote order for service What is the consulting MD - ANS: who consults with another MD How long does Medicare Part A cover inpat services? - ANS: 60 days, then 30 co-insurance, then pt can use 60 days of lifetime reserve HICN - ANS: healthcare insurance claim # issued by SSN to those elgible for SSN How often does Medicare update co-insurance amounts for Part B? - ANS: yearly done by OPPS, outpt prospective pymnt system How are payments under -Care A paid? what system? - ANS: based on DRGs (more than more ACOs), reasonable cost at CAHs, rehab hosp, psych, ped, lg term care hosp How are payments under -Care B paid? what system? - ANS: paid on ambulatory paymt classification (APC), prospective pymt rates What are some unique sources of information that must be provided when submitting a claim to -Caid? - ANS: -Caid ID # must be on form, newborn weight must be incl Can IHS pts receive care at other clinics? - ANS: Yes, but IHS must be the payer of last resort What must be on the UB-04 or CMS 1500 for BCBS pts? - ANS: Alpha prefix - specifies specific BCBS What law governs self insured companies - ANS: ERISA - ergo not controlled by state legislation Can -Care be billed after billing a liability payer? - ANS: yes, after 120 days. Must release liability and - Care will pursue liability payer What are typical claim edits? - ANS: medical necessity, invalid demo info, invalid codes, missing NPI #s

Name three aspects to the Hospital Readmit Reduction Act - ANS: CMS reduces pymt to hosp w/ excessively high readmit for heart, COPD, pneumonia, knee replace; also to MDs who do not report qual data Why is the charge master imptt even in managed care? - ANS: reimbursemt based on % of charges or stop loss based on total What are the two components of the charge master - ANS: room and board (by nursing unit, room type) and ancillary charges - will list UB-04 rev code, CPT/HCPCS code and charge amount What are level 1 CPT codes - ANS: five numbers (for procedures) What are level 2 CPT codes - ANS: for supplies, ambulance (alpha and 4 digits) What are level 3 CPT codes - ANS: not common What are level 1 CPT modifiers - ANS: eg would be 23 - unusual anesthesia What are level 11 CPT modifiers - ANS: eg: LT - left side, E4 - lower right eyelid What are level III CPT modifiers - ANS: XI - FDA approved drug Is there a chain to modifiers? - ANS: Yes, a HCPCS level III has higher precedence than a HCPCS NP level II for example In Pay for Performance, what do hospitals do in the Hosp Qual Initiative? - ANS: hosp must submit data about 10 quality measures In Pay for Performance, what must hospitals do in the Premier Hosp Quality initiative? - ANS: If hosp score in top 10%, receive a 2% bonus, if not meet objectives, subject to reductions

In Pay for Performance, what must hospitals do in the capitation type initiative? - ANS: for chronically ill, must guarantee CMS a savings of at least 5% over similar population What is Pay for Performance? - ANS: Pay-for-performance" is an umbrella term for initiatives aimed at improving the quality, efficiency, and overall value of health care. Pay-for-performance has become popular among policy makers and private and public payers, including Medicare and Medicaid. Formula for Net Days in Pt A/R - ANS: Net Pt A/R

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Net Revenue/365 (or time period) What does Net Days in Pt A/R tell us? - ANS: indication of efficiency of collections, revenue posting, and financial ops of A/R Does Net Days in Pt A/R get aged from date of service, date bill sent, or? - ANS: Date of service What is goal for aging A/R >90 days - ANS: 15-18% What is goal for aging A/R >1 yr - ANS: <1% What is goal for time for charge posting - ANS: w/in 1-3 days of service What is goal for credit balance - ANS: <1% of billed A/R What is goal for charity and bad debt - ANS: 5-8% of billed A/R What should be taken into account when estimating net revenue (for future) - ANS: historical adjustments, new payer contracts, charity care, bad debt

What are reserves? - ANS: how much is not yet collected What is important about reserves - ANS: needs to be as accurate as possible - if caught off guard, could impact available funds What % of reserves are self pay bills >120 days from 1st bill - ANS: 100% What % of reserves are self pay bills 90-120 days from 1st bill - ANS: 50% What % of reserves are self pay bills 60-90 days from 1st bill - ANS: 25% What % of reserves are medicare bills >365 days past discharge - ANS: 20% What % of reserves are medicare bills 180-365 days past discharge - ANS: 10% Are gross charges or contractural amounts posted to a pt's account? - ANS: If know contractural amount can post, otherwise post gross charge to pt's account until insurance pays What are instances when -care is a 2ndry payer? - ANS: Disability (pt <65, has LGHP), ESRD (in 30 day coordination period), working aged, accident (when no liability exists) What is the correct coding initiative? - ANS: the purpose of the CCI is to ensure that the most comprehensive groups of codes are billed, rather than the component parts. developed by CMS What are some ways to avoid problems with cash postings? - ANS: large write-offs such as bad debt should be done by managers. What does CMS require when there is a credit balance? - ANS: reporting to CMS What does HFMA recommend a HCO do with a small credit to a pt payer? - ANS: absorb if pt does not claim after a certain period of time

What is a bank lock box? - ANS: contracting with a bank to receive, deposit, and electronically report payments from pts and payers What were the four goals of HIPAA passed in 1996? - ANS: portability - the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs; Reduces health care fraud and abuse; Mandates industry-wide standards for health care information on electronic billing and other processes; and Requires the protection and confidential handling of protected health information What is APC? - ANS: Ambulatory payment classification: United States government's method of paying for facility outpatient services for Medicare. analogous to the Medicare prospective payment system for hospital inpatients (DRG). APCs are an outpatient prospective payment system applicable only to hospitals. What is case rate? - ANS: fixed price for specified procedure. Gives provider opportunity to manage costs before capitation. What is a silent PPO - ANS: insurance companies that offer providers less payment, invalid discounts (they try to look like a contracted PPO) What is electronic remittance advice 835 data set? - ANS: used to send hc claim payments and advice - four levels from receipt (then paper trail) to level 4 - all electronic and links bank. -Care uses level 4. Can a Medicare beneficiary request an appeal? - ANS: yes, must be an amount >$130, judicial review if over $ Can a provider request a -Care appeal? - ANS: yes, must be >$1000; and on Part A, only on medical necess If a beneficiary knew services would not be provided, is he liable for payment? - ANS: Yes

If neither provider nor beneficiary knew services wouldn't be covered, are they liable? - ANS: No, -Care must cover. But must have been reasonable to have not known. If provider should have known services wouldn't be covered and didn't give ABN, are they liable? - ANS: Yes What criteria should be used to evaluate a collection agency? - ANS: reputation, pt relations, agency fees (they should give an estimated recovery amount), 'no recovery, no fee' What is a rentention account (in regards collection agency)? - ANS: Holding trust account where recovered monies are kept until transferred to the provider What is Chpt 7 bankruptcy? - ANS: straight bankruptcy What is Chpt 11 bankruptcy? - ANS: debtor reorg - bankruptor has continuing management of business, debtor creates plan to reorg, creditors must approve, may also involve reduction in debt amounts What is Chpt 13 bankruptcy? - ANS: debt rehab - no liquidation, reorg holdings, creditors look to future earnings (eg garnishment) What is exempt in bankruptcy? - ANS: property (like house, personal items), alimony, tools of trade What is exempted from discharge in bankruptcy? - ANS: education loans, gvt fines, unpaid alimony/child care, debts arisen from lying FAP (financial assistance program) and its charity agreements? - ANS: non-profits will have limitations on charges to uninsured how should a HCO determine poverty guidelines? - ANS: Can use the federal poverty guidelines, income does not include capital gain, injury comp, sale of property - and is state defined

What is catastrophic charity - ANS: in the event of catastrophic injury or illness what is an open insurance balance? - ANS: After 60 days, pt must pay or fight with insurance co. to pay (unless prohibitions in contract) what is subrogation? - ANS: health plan bills liability insurance Will -Care pay for worker's comp - ANS: No Will -Care pay for auto liability? - ANS: Yes, after auto is exhausted What percent of claims and type are 80% of AR? - ANS: 15-20% of high fee What's an example of a claim rejection for technical reasons? - ANS: demographic errors, no pre- authorization, exceeded frequency (only 1 PAP/yr) What's an example of a claim rejection for clinical reason? - ANS: missing doc to support, HCPCS incorrect, not medically necessary What does a recovery audit contractor do? - ANS: Review -Care claims to save gvt $ and prevent abuse What is unique about a rural health clinic and how it bills -Care part B - ANS: Can collapse CPT codes to 520, but HFMA recommends still use CPT for medical necessity Are all -Care services in a RHC defined as rural health? - ANS: No, such as SNF How are -Caid claims paid in a RHC? - ANS: state by state rules Will -Care pay for a VA hospice? - ANS: No, VA must pay

Will - Care pay for hospice? - ANS: Only if pt is entitled to -Care part A Can hospice be denied under -Care? - ANS: yes, if worker's comp related or >210 days of hospice How is hospice payment worker compensation related? - ANS: Could be cancer caused by exposure, worker's comp must cover, but -Care would then cover respite care, eg Will -Care cover hospice in a SNF? - ANS: Only hospice symptom managemnt, not room and board Will -Care cover SNF? - ANS: only if discharge not transfer What is mandatory if -Care will cover SNF? - ANS: must be to cover condition had at inpt, must have 3+ days inpt (can be at 1+ hosp, if consec), must need daily, skilled nursg service, MD must sign Is there co-insurance at a SNF for -Care? - ANS: Yes, from 21st-100th day How are SNFs paid under -Care? - ANS: per diem based on case mix According to the ACA, when must claims be submitted by? - ANS: w/in 1 year, starts on: institution: through date, MD: from date Hospice type payments are? - ANS: A - routine (paid ~ rate each day), B- continuous (/24 to get hrly rate), C-inpt respite (5 days for family respite), D-inpt general - a, C, D - one rate applies each day, B - determined on # of hrs continuous care provided that day Are all ambulance bills paid directly to an ambulance company? - ANS: No, if ambulance use is required for transfer w/in hosp, then billed under Part A (eg, obese pt who cannot fit in MRI) Is there only one way an ambulance bill is billed? - ANS: No, can be one rate (incl all), or one rate for services, separate for mileage, opposite of last, base rate, separate charges for both

How is medical necessity determined in ambulance? - ANS: based on services provided, not type of ambulance used What is the FCA - ANS: False Claims Act of 2009, fraud enforcement and recovery act, encourage whistleblowers When is -Care a MSP? - ANS: group health plan, only if >20 employees, accident (some specifics on liability), disability (Unless >65), ESRD in 30 coordination period What is the 2 midnight rule - ANS: 2 midnights or less can be outpt What is the CCI - ANS: correct coding initiative - modifiers to help indicate a special circumstance (eg performed by > 1 MD) What are the 9 forms that should be on hand on admission - ANS: consent to treatment condition of admission (financial agreement, surgical consent, release of info, assignment of benefits) privacy notice impt msg from -Care (can dispute) ADP Pt bill of rights How should a PFS introduce payment when speaking with a pt? - ANS: 1. greet

2. review HCO PFS policies
3. review insurance
4. review charges and liability
5. how will pt resolve liability? What are some problems if pt access not done correctly? - ANS: 1. billing (lost revenue)
6. clinical - in wrong file
7. case review - where insurance must be notified w/in 24 hrs

4. legal What is the FDCA? - ANS: Fair Debt Collection Act Hosp benchmark days A/R - ANS: 40-