Healthcare Financial Management Terminology and Concepts, Exams of Finance

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CRCR Exam Prep 146 Questions and Answers 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 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 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 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 What statement applies to the scheduled outpatient? - ✅The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - ✅Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount What type of patient status is used to evaluate the patient's need for inpatient care? - ✅Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - ✅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$? - ✅When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - ✅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? - ✅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 If a patient remains an inpatient of an SNF (skilled nursing facility for more than 30 days, what is the SNF permitted to do? - ✅Submit interim bills to the Medicare program. 90. MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - ✅120 days passes, but the claim then be withdrawn from the liability carrier What data are required to establish a new MPI entry? - ✅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? - ✅Determine the correct payer and notify the incorrect payer of the processing error What do EMTALA regulations require on-call physicians to do? - ✅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? - ✅They must be balanced What will cause a CMS 1500 claim to be rejected? - ✅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? - ✅The cost of the test how are HCPCS codes and the appropriate modifiers used? - ✅To report the level 1, 2, or 3 code that correctly describes the service provided If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - ✅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? - ✅Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - ✅Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - ✅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? - ✅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 What technique is acceptable way to complete the MSP screening for a facility situation? - ✅Ask if the patient's current services was accident related What is a valid reason for a payer to delay a claim? - ✅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 - ✅They must be combined with the inpatient bill and paid under the MS-DRG system What do large adjustments require? - ✅Manager-level approval What items are valid identifiers to establish a patient's identification? - ✅Photo identification, date of birth, and social security number What must a provider do to qualify an account as a Medicare bad debts? - ✅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? - ✅Site-of-service limitation What is an example of an outcome of the Patient Friendly Billing Project? - ✅Redesigned patient billing statements using patient-friendly language What statement describes the APC (Ambulatory payment classification) system? - ✅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 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 - ✅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 - 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 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? - ✅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