Healthcare Insurance Terminology and Concepts, Exams of Nursing

Download Healthcare Insurance Terminology and Concepts and more Exams Nursing in PDF only on Docsity! CRCR EXAM MULTIPLE CHOICE, CRCR Exam Prep, Certified Revenue Cycle Representative - CRCR (2021) Review/ 530+ Q&A. 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 Page 1 of 118 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 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 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 Page 2 of 118 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 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 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 Page 5 of 118 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 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 Page 6 of 118 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) 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 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 Page 7 of 118 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 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 Page 10 of 118 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 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 Page 11 of 118 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 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 Page 12 of 118 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 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 Claim - Answer: A demand by an insured person for the benefits provided by the group contract Page 15 of 118 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 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 Page 16 of 118 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 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 Self-insured - Answer: Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Page 17 of 118 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 - Answer: 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? - Answer: Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations FERA - Answer: Fraud Enforcement and Recovery act ESRD - Answer: 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? - Answer: Mitigate potential fraud and abuse in the industry-specific key risk areas What is important about an effective corporate compliance program? - Answer: 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 Page 20 of 118 What is a CCO - Answer: 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? - Answer: 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. - Answer: TRUE The OIG has issued compliance guidance/model compliance plans for all of the following entities: - Answer: hospices. physician practices. ambulance providers Providers who are found to be in violation of CMS regulations are subject to: - Answer: Corporate integrity agreements What MSP situation requires LGHP - Answer: Disability The disadvantages of outsourcing include all of the following EXCEPT: a) The impact of customer service or patient relations b) The impact of loss of direct control of accounts receivable services c) Increased costs due to vendor ineffectiveness d) Reduced internal staffing costs and a reliance on outsourced staff - Answer: D Page 21 of 118 The Medicare fee-for service appeal process for both beneficiaries and providers includes all of the following levels EXCEPT: a) Medical necessity review by an independent physician's panel b) Judicial review by a federal district court c) Redetermination by the company that handles claims for Medicare d) Review by the Medicare Appeals Council (Appeals Council) - Answer: B 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 - Answer: A 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 - Answer: A Page 22 of 118 d) The development of operational policies that correspond to regulations - Answer: C 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 - Answer: B Pricing transparency is defined as readily available information on the price of healthcare services, that together with other information, help define the value of those services and enable consumers to a) Identify, compare, and choose providers that offer the desired level of value b) Customize health care with a personally chosen mix of providers c) Negotiate the cost of health plan premiums d) Verify the cost of individual clinicians - Answer: A 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 Page 25 of 118 a) MSO b) HMO c) PPO d) GPO - Answer: B In a Chapter 7 Straight Bankruptcy filing a) The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt b) The court liquidates the debtor's nonexempt property, pays creditors, and begins to pay off the largest claims first. All claims are paid some portion of the amount owed c) The court vacates all claims against a debtor with the understanding that the debtor may not apply for credit without court supervision d) The court establishes a creditor payment schedule with the longest outstanding claims paid first - Answer: A The core financial activities resolved within patient access include: a) Scheduling, pre-registration, insurance verification and managed care processing b) Scheduling, insurance verification, clinical discharge processing and payment posting of point of service receipts c) Scheduling, registration, charge entry and managed care Page 26 of 118 processing d) Scheduling, pre-registration, registration, medical necessity screening and patient refunds - Answer: A Which of the following is NOT contained in a collection agency agreement? a) A clear understanding that the provider retains ownership of any outsourced activities b) Specific language as to who will pay legal fees, if needed c) An annual renewal clause d) A mutual hold-harmless clause - Answer: D Maintaining routine contact with the health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of: a) Patient Accounts b) Managed Care Contract Staff c) HIM staff d) Case Management - Answer: D What is required for the UB-04/837-I, used by Rural Health Clinics to generate payment from Medicare? Page 27 of 118 d) The subscriber was not enrolled at the time of service - Answer: C 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 - Answer: D 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 - Answer: ???Number 24??? 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 Page 30 of 118 c) The portion of the bill outside of the patient's self-pay d) Transports deemed medically necessary by the attending paramedic-ambulance crew - Answer: C 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 - Answer: A The nuanced data resulting from detailed ICD-10 coding allows senior leadership to work with physicians to do all of the following EXCEPT: a) Drive significant improvements in the areas of quality and the patient experience b) Embrace new reimbursement models c) Improve outcomes d) Obtain higher compensation for physicians - Answer: D Duplicate payments occur: Page 31 of 118 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 - Answer: a The Affordable Care Act legislated the development of Health Insurance Exchanges, where individuals and small businesses can a) Purchase qualified health benefit plans regardless of insured's health status b) Obtain price estimates for medical services c) Negotiate the price of medical services with providers d) Meet federal mandates for insurance coverage and obtain the corresponding tax deduction - Answer: A The most common resolution methods for credit balances include all of the following EXCEPT: Page 32 of 118 d) A representative of the health plan be included in the patient financial responsibilities discussion - Answer: B When there is a request for service, the scheduling staff member must confirm the patient's unique identification information to a) Check if there is any patient balance due b) Verify the patient's insurance coverage if the patient is a returning customer c) Confirm that physician orders have been received d) Ensure that she/he accesses the correct information in the historical database - Answer: D Once the price is estimated in the pre-service stage, a provider's financial best practice is to a) Explain to the patient their financial responsibility and to determine the plan for payment b) Allow the patient time to compare prices with other providers c) Lock-in the prices d) Have another employee double check the price estimate - Answer: A Page 35 of 118 What type of account adjustment results from the patient's unwillingness to pay a self- pay balance? a) Charity adjustment b) Bad debt adjustment c) Contractual adjustment d) Administrative adjustment - Answer: B 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 - Answer: D All of the following are forms of hospital payment contracting EXCEPT a) Contracted Rebating b) Per Diem Payment c) Fixed Contracting d) Bundled Payment - Answer: A Page 36 of 118 Overall aggregate payments made to a hospice are subject to a computed "cap amount" calculated by: a) The Center for Medicare and Medicaid Services (CMS) b) Each state's Medicaid plan c) Medicare d) The Medicare Administrative Contractor (MAC) at the end of the hospice cap period - Answer: D With the advent of the Affordable Care Act Health Insurance Marketplaces and the expansion of Medicaid in some states, it is more important than ever for hospitals to a) Reschedule the visit for non-payment of a prior balance b) Strictly limit charity care and bad-debt c) Collect patient's self-pay and deductibles in the first encounter d) Assist patients in understanding their insurance coverage and their financial obligation - Answer: D 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 Page 37 of 118 Medicare will only pay for tests and services that a) Constitute appropriate treatment and are fairly priced b) Have solid documentation c) Can be demonstrated as necessary d) Medicare determines are "reasonable and necessary" - Answer: D Room and bed charges are typically posted a) From case management reports generated for contracted payers b) Through the case management daily resource report c) At the end of each business day d) From the midnight census - Answer: D The process of creating the pre=registration record ensures a) Ability to pursue extraordinary collection activities b) Early and productive communication with a third-party payer c) Accurate billing d) That access staff will have the compete and valid information needed to finalize any remaining pre-access activities - Answer: C Once the EMTALA requirements are satisfied a) Third-party payer information should be collected from the patient and the payer should be notified of the ED visit b) The patient then assumes full liability for services unless a third- Page 40 of 118 party is notified or the patient applies for financial assistance with the first 48 hours c) The remaining registration processing is initiated at the bedside or in a registration area d) An initial registration records is completed so that the proper coding can be initiated - Answer: C This directive was developed to promote and ensure healthcare quality and value and also to protect consumers and workers in the healthcare system. This directive is called a) Payer quality monitoring b) Medicare patient and staff safety standards c) Joint Commission for Accreditation of Healthcare Organizations (JCAHO) safety d) Patient bill of rights - Answer: D 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 Page 41 of 118 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. - Answer: C The first and most critical step in registering a patient, whether scheduled or unscheduled, is a) Having the patient initial the HIPAA privacy statement b) Verifying insurance to activate the patient medical record c) Verifying the patient's identification d) Check the schedule for treatment availability - Answer: C The legal authority to request and analyze provider clam documentation to ensure that IPPS services were reasonable and necessary is given to a) Recovery Audit Contractors (RAC) b) The Office of the U.S. Inspector General (OIG) c) All health plans d) State insurance commissioners - Answer: B 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 Page 42 of 118 a) Understanding of billing issues and the deductibles and/or co-insurance due for the current visit b) Right to refuse to use lifetime reserve days for the current stay c) Right to appeal a discharge decision if the patient disagrees with the plan d) Obligation to reimburse the hospital for any services not covered by the Medicare program - Answer: C 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 - Answer: D Medicare Part B has an annual deductible, and the beneficiary is responsible for a) A co-insurance payment for all Part B covered services b) Physicians office fees c) Tests outside of an inpatient setting d) Prescriptions - Answer: A The importance of medical records being maintained by HIM is that the patient records a) Are the primary source for clinical data required for reimbursement by Page 45 of 118 health plans and liability payers b) Are the strongest evidence and defense in the event of a Medicare audit c) Are evidence used in assessing the quality of care d) Are the evidence cited in quality review - Answer: A 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 - Answer: A Medicare has established guidelines called the Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) that establish a) Provider and physician reimbursement for specific diagnoses and tests b) Prospective Medicare patient financial responsibilities for a given diagnosis c) Reasonable and customary prices for services in a given area d) What services or healthcare items are covered under Medicare - Answer: D Page 46 of 118 What are some core elements if a board-approved financial assistance policy? a) Payment requirements, staffing hours, and admission policies b) Case management, payment methods, and discharge policies c) Deposit requirements, pre-registration calling hours, and charity care policy d) Eligibility, application process, and nonpayment collection activities - Answer: D The ICD-10 codes set and CPT/HCPCS code sets combines provide a) Pricing floors for services b) The financial data required for activity-based costing c) Patients an overview of services covered by their health insurance plan d) The specificity and coding needed to support reimbursement claims - Answer: D 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 - Answer: B Under EMTALA (Emergency Medical Treatment and Labor Act) regulations, the provider Page 47 of 118 c) Monitoring the costs and charges the patient incurs d) Inquisitive, responsive and flexible - Answer: A Hospitals need which of the following information sets to assess a patient's financial status: a) Income, expenses, debt b) Patient and guarantor's income, expenses and assets c) Income, expenses and capacity to take on more debt d) Assets liquidity, Income, expenses, credit worthiness - Answer: B 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 - Answer: C The Electronic Remittance Advice (ERA) data set is : a) Used for Electronic Funds Transfers between hospitals and a bank b) A standardized form that provides 3rd party payment details to providers Page 50 of 118 c) Required for annual Medicare quality reporting forms d) Safeguards the Electronic claims process - Answer: B 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 - Answer: C 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 - Answer: A Indemnity plans usually reimburse: a) Only for contracted Services b) A claim up to 80% of the charges c) A certain percentage of the charges after the patient meets the policy's annual deductible d) A patient for out-of-pocket charges - Answer: C Page 51 of 118 Because 501(r) regulations focus on identifying potential eligible financial assistants patients hospitals must: a) Capture their experience 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 - Answer: B Which option is a benefit of pre-registering a patient for services a) The patient arrival process is expedited, reducing wait times and delays b) The verification of insurance after completion of the services c) Service departments have the ability to override schedules and block time to reduce testing volume d) The patient receiving multiple calls from the provider - Answer: A 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 Page 52 of 118 b) ICD-10 Procedural codes c) CPT codes d) Revenue codes - Answer: D The importance of Medical records being maintained by HIM is that the patient records: a) Are evidence used in assessing the quality of care b) Are the primary source for clinical data required for reimbursement by health plans and liability payers C) Are the strongest evidence and defense in the event of a Medicare Audit d) Are the evidence cited in quality review - Answer: B Medicare patients are NOT required to produce a physician order to receive which of these services a) Diagnostic Mammography, flu vaccine, or B-12 shots b) Diagnostic Mammography, flu vaccine, or pneumonia vaccine c) Screening Mammography, flu vaccine or pneumonia vaccine d) Screening Mammography, flu vaccine or B-12 shots - Answer: C Patients should be informed that costs presented in a price estimate may a) Vary from estimates, depending on the actual services performed b) Be guaranteed if the patient satisfies all patient financial responsibilities at the time of registration Page 55 of 118 c) Be lower as price estimates use the highest market price d) Only determine the percentage of the total that the patient is responsible for and not the actual cost - Answer: A 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 - Answer: C In Chapter 7 straight bankruptcy filling a) The court establishes a creditor payment schedule with the longest outstanding claims paid first b) The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt c) The court vacates all claims against a debtor with the understanding that the debtor may not apply for credit without court supervision d) The court liquidates the debtor's nonexempt property, pays creditors, and begins to Page 56 of 118 pay off the largest claims first. All claims are paid some portions of the amount owed. - Answer: B The activity which results in the accurate recording of patient bed and level of care assessment, patient transfer and patient discharge status on a real-time basis is known as a) Utilization review b) Case management c) Census management d) Patient through-put - Answer: B Which of the following is required for participation in Medicaid a) Obtain a supplemental health insurance policy b) Meet income and assets requirements c) Meet a minimum yearly premium d) Be free of chronic conditions - Answer: B When primary payment is received, the actual reimbursement a) Is compared to the expected reimbursement b) Is recorded by Patient Accounting and the patient's account is the closed c) Is compared to the expected reimbursement, the remaining contractual adjustments are posted, and secondary claims are submitted Page 57 of 118 reimbursements must be calculated d) Review contracts to ensure the appeals process for denied claims is clearly specified - Answer: A The benefit of Medicare Advantage Plan is a) It is a less costly plan compared to traditional Medicare b) Patients may retain a primary care physician and see another physician for a second opinion at no charge c) Patients generally have their Medicare-coverage healthcare through the plan and do not need to worry about "part a" or "part b" benefits d) Patients receive significant discounting on services contracted by the federal government - Answer: C Once the EMTALA requirements are satisfied a) Third-party payer info should be collected from the pt and the payer should be notified of the ED visit b) An initial registration record is completed so that the proper coding can be initiated c) The pt then assumes full liability for services unless a third-party payer is notified or the pt applies for financial assistance within the first 48 hours d) The remaining registration processing is initiated either at the bedside or In a registration area - Answer: A Page 60 of 118 The soft cost of a dissatisfied customer is a) The "cost" of staff providing extra attention in trying to perform service recovery b) The customer passing on info about their negative experience to potential pts or through social media channels c) Potentially negative treatment outcomes leading to expanding length-of-stay d) Lowered quality outcomes for the dissatisfied pt - Answer: B 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 - Answer: A In a self-insured (or self-funded) plan, the costs of medical care are a) Borne by the employer on a pay-as-you-go basis b) Backed-up by stop-loss insurance against a catastrophic claim c) Mandated by the Affordable Care Act for small businesses unable to obtain commercial coverage d) Created by a combination of employer and employee contributions - Answer: A In choosing a setting for pt financial discussions, organizations should first and foremost a) Have processes in place to document the discussions Page 61 of 118 b) Assess locations for convenience, professionalism, and comfort c) Respect the pts privacy d) Ensure all staff involved are properly trained and the pt financial education is included in all discussions - Answer: C 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 - Answer: D Which option is a government-sponsored health care program that is financed through taxesand general revenue funds a) Medicaid b) Medicare c) Insurance exchange d) Social security - Answer: B It is important to calculate reserves to ensure a) Stable financial operations and accurate financial reporting b) Collateral for credit c) Expense coverage in the event of a revenue short fall d) Coverage of B/D write offs and charity care costs - Answer: A Page 62 of 118 d) Explain to the pt their financial responsibility and to determine the plan for payment - Answer: D 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 - Answer: A 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 - Answer: A 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 - Answer: C Page 65 of 118 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 - Answer: A Pt financial communications best practices produce communications that are a) Timely and remind pts of their financial responsibilities b) Consistent, clear and transparent c) Current and report the status of a pts claim d) Timely, comprehensive and specifying next steps - Answer: B Key performance indicators (KPIs) set standards for accounts receivables (A/R) and a) Establish productivity targets b) Provide a method of measuring the collection and control of A/R c) Provide evidence of financial status d) Make allowance for accurate revenue forecasting - Answer: B When Recovery Audit Contractors (RAC) identify improper payments as over payments, Page 66 of 118 the claims processing contractor must a) Assume legal responsibility for repaying the overage amount b) Make recovery of the overpayment the top processing priority c) Send a demand letter to the provider to recover the over payment amount d) Conduct an audit of all the effected providers claims within the past twelve months - Answer: C 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 - Answer: A It is important to have high registration quality standards because a) Inaccurate or incomplete pt data will delay payment or cause denials b) Incomplete registrations will trigger exclusion from Medicare participation c) Inaccurate registration may cause discharge before full treatment is obtained d) Incomplete registrations will raise satisfaction scores for the hospital - Answer: A When recovery audit contractors (RAC) identify improper payments as over payments the claims processing contractor must a) Assume legal responsibility for repaying the overage amount Page 67 of 118 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 - Answer: A 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 - Answer: B Telemed seeks to improve a pt's health by a) Permitting 2-way real time interactive communication between the pt and the clinical professional b) Using high-compression fiber optics to transmit medical data c) Providing relevant, on-demand consumer medical education d) Providing physician access to the most current medical research - Answer: A 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 Page 70 of 118 c) Inadequate staff training d) Banking transaction errors - Answer: A 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 - Answer: C The office of inspector general (OIG) publishes a compliance work plan a) Monthly b) Quarterly c) Semi-annually d) Annually - Answer: D What are collection agency fees based on? - Answer: A percentage of dollars collected Page 71 of 118 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 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 Page 72 of 118 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 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 Page 75 of 118 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 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 Page 76 of 118 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) 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 Page 77 of 118 what organization originated the concept of insuring prepaid health care services? - Answer: Blue Cross and blue Shield 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 How does utilization review staff use correct insurance information? - Answer: To obtain approval for inpatient days and coordinate services Page 80 of 118 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 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 Page 81 of 118 What option is an alternative to valid long-term payment plans? - Answer: Bank loans 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 How may a collection agency demonstrate its performance? - Answer: Calculate the rate of recovery Page 82 of 118 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 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 Page 85 of 118 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 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 Page 86 of 118 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 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 Page 87 of 118 Out of pocket payment - Answer: The portion of the total payment for medical services and treatment for which the patient is responsible, including copayments, coinsurance, and deductibles Price transparency - Answer: 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 - Answer: 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? - Answer: Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations FERA - Answer: Fraud Enforcement and Recovery act ESRD - Answer: 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? - Answer: Mitigate potential fraud and abuse in the industry-specific key risk areas Page 90 of 118 What is important about an effective corporate compliance program? - Answer: 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 - Answer: 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? - Answer: 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. - Answer: TRUE The OIG has issued compliance guidance/model compliance plans for all of the following entities: - Answer: hospices. physician practices. ambulance providers Providers who are found to be in violation of CMS regulations are subject to: - Answer: Corporate integrity agreements What MSP situation requires LGHP - Answer: Disability Page 91 of 118 Which of the following statements are true of HFMA's Financial Communications Best Practices - Answer: The best practices were developed specifically to help patients understand the cost of services, their individual insurance benefits, and their responsibility for balances after insurance, if any. The patient experience includes all of the following except: - Answer: The average number of positive mentions received by the health system or practice and the public comments refuting unfriendly posts on social media sites. 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: - Answer: All of the above Specific to Medicare fee-for-service patients, which of the following payers have always been liable for payment? - Answer: Public health service programs, Federal grant programs, veteran affairs programs, black lung program services and work- related injuries and accidents (worker' compensation claims) Provider policies and procedures should be in place to reduce the risk of ethics violations. Examples of ethics violations include: - Answer: All of the above Providers are now being reimbursed with a focus on the value of the services provided, rather than volume, which requires collaboration among providers. Page 92 of 118 C. The encounter record is generated, and the patient and guarantor information is obtained and/or updated as required. D. The focus is on the patient and his/her financial care, in addition to the clinical care provided for the patient. The following statements describe best practices established by the Medical Debt Task Force. Check the box next to the True statements - Answer: **Educate Patients **Coordinate to avoid duplicate patient contacts Exercise moderate judgement when communicating with providers about scheduled services **Be consistent in key aspects of account resolution Report to healthcare plans when the patient's account is transferred to collection agency **Follow best practices for communication Which option is NOT a main HFMA Healthcare Dollars & Sense® revenue cycle initiative? - Answer: A. Patient Financial Communications B. Price Transparency C. Medical Account Resolution Page 95 of 118 **D. Process Compliance What is the objective of the HCAHPS initiative? - Answer: **A. To provide a standardized method for evaluating patients' perspective on hospital care. B. To provide clear communication and good customer service, which will give the provider a competitive edge. C. To conduct evaluations concerning patients' perspective on hospital care. D. To make certain that during registration key information is verified by means of a picture ID and an insurance card. Which option is NOT a department that supports and collaborates with the revenue cycle? - Answer: A. Information Technology B. Clinical Services C. Finance **D. Assisted Living Services Which option is NOT a continuum of care provider? - Answer: A. Physician **B. Health Plan Contracting C. Hospice D. Skilled Nursing Facility Which of the following are essential elements of an effective compliance program? - Answer: **Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines Page 96 of 118 **Established compliance standards and procedures Automatic dismissal of any employee excluded from participation in a federal healthcare program **Designation of a compliance officer employed within the Billing Department **Oversight of personnel by high-level personnel. 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. - Answer: A. 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 In order to promote the use of correct coding methods on a national basis and prevent payment errors due to improper coding, CMS developed what? - Answer: **A. The Correct Coding Initiative (CCI) B. The Advance Beneficiary Notice of Noncoverage (ABN) C. The Medicare Secondary Payer (MSP) D. Modifiers Page 97 of 118