Healthcare Insurance Terminology and Concepts, Exams of Advanced Education

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CRCR EXAM | Latest Update | 100% Correct Verified Answers What are collection agency fees based on? - Correct Answer-A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - Correct Answer-Birthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - Correct Answer-Case rates What customer service improvements might improve the patient accounts department? - Correct Answer-Holding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - Correct 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? - Correct Answer-Bad debt adjustment What is the initial hospice benefit? - Correct Answer-Two 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - Correct 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? - Correct 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 - Correct Answer-They are not being processed in a timely manner What is an advantage of a preregistration program? - Correct Answer-It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - Correct Answer- Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - Correct Answer- Scheduling, insurance verification, discharge processing, and payment of point-of- service receipts What statement applies to the scheduled outpatient? - Correct Answer-The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - Correct Answer-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? - Correct Answer-Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - Correct 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$? - Correct Answer-When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - Correct 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? - Correct Answer-Neither enrolled not entitled to benefits Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what? - Correct Answer-Disclosure rules for consumer credit sales and consumer loans What is a principal diagnosis? - Correct Answer-Primary reason for the patient's admission Collecting patient liability dollars after service leads to what? - Correct Answer-Lower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - Correct 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? - Correct Answer-Inpatient care What code indicates the disposition of the patient at the conclusion of service? - Correct Answer-Patient discharge status code Under Medicare regulations, which of the following is not included on a valid physician's order for services? - Correct Answer-The cost of the test how are HCPCS codes and the appropriate modifiers used? - Correct Answer-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? - Correct 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? - Correct Answer-Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - Correct Answer- Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - Correct 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? - Correct Answer-Blue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? - Correct 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? - Correct 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? - Correct Answer-Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? - Correct Answer- Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - Correct Answer-Code of conduct How does utilization review staff use correct insurance information? - Correct Answer- To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - Correct Answer-As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - Correct 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? - Correct Answer-Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - Correct Answer-Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail How are patient reminder calls used? - Correct 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? - Correct 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? - Correct Answer-Sale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - Correct Answer-A condition code What option is an alternative to valid long-term payment plans? - Correct Answer-Bank loans What is an advantage of using a collection agency to collect delinquent patient accounts? - Correct Answer-Collection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? - Correct 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 - Correct Answer-catastrophic charity What happens when a patient receives non-emergent services from and out-of-network provider? - Correct Answer-Patient payment responsibility is higher Every patient who is new to the healthcare provider must be offered what? - Correct Answer-A printed copy of the provider's privacy notice How may a collection agency demonstrate its performance? - Correct 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? - Correct 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? - Correct Answer-The UB-04 and the CMS 1500 Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information? - Correct Answer-Obtain the required demographic and insurance information before services are rendered what protocol was developed through the Patient Friendly Billing Project? - Correct Answer-Provide information using language that is easily understood by the average reader What technique is acceptable way to complete the MSP screening for a facility situation? - Correct Answer-Ask if the patient's current services was accident related What is a valid reason for a payer to delay a claim? - Correct 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 - Correct Answer-They must be combined with the inpatient bill and paid under the MS-DRG system What do large adjustments require? - Correct Answer-Manager-level approval What items are valid identifiers to establish a patient's identification? - Correct Answer- Photo identification, date of birth, and social security number What must a provider do to qualify an account as a Medicare bad debts? - Correct 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? - Correct Answer-Site-of-service limitation What is an example of an outcome of the Patient Friendly Billing Project? - Correct Answer-Redesigned patient billing statements using patient-friendly language What statement describes the APC (Ambulatory payment classification) system? - Correct Answer-APC rates are calculated on a national basis and are wage-adjusted by geographic region Third-part administrator (TPA) - Correct Answer-Provides services to employers or insurance companies for utilization review, claims payment and benefit design Third-party reimbursement - Correct Answer-A general term used for the healthcare benefit payments - used to identify that for benefit plans there are three parties in the transaction Usual, customary, and reasonable (UCR) - Correct Answer-Health insurance plan reimbursement methodology that limits payment to the lower billed charges, the provider's customary charge, or the prevailing charge for the service in the community Utilization review - Correct Answer-Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Charge - Correct Answer-The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Cost - Correct Answer-The definition of cost varies by party incurring the expense Price - Correct Answer-the total amount a provider expects to be paid by payers and patients for healthcare services Care purchaser - Correct Answer-Individual or entity that contributes to the purchase of healthcare services Payer - Correct Answer-An organization that negotiates or sets rates for provider services, collects revenue through premium payments or tax dollars, processes provider claims for service, and pays provider claims using collected premium or tax revenues Provider - Correct Answer-An entity, organization, or individual that furnishes a healthcare service Out of pocket payment - Correct 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 - Correct 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 - Correct 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? - Correct Answer-Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations FERA - Correct Answer-Fraud Enforcement and Recovery act ESRD - Correct 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? - Correct Answer-Mitigate potential fraud and abuse in the industry-specific key risk areas What is important about an effective corporate compliance program? - Correct 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 - Correct 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? - Correct 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. - Correct Answer-TRUE The OIG has issued compliance guidance/model compliance plans for all of the following entities: - Correct Answer-hospices. physician practices. ambulance providers Providers who are found to be in violation of CMS regulations are subject to: - Correct Answer-Corporate integrity agreements What MSP situation requires LGHP - Correct 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 - Correct Answer- D 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) - Correct 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 - Correct 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 - Correct Answer-A Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) are Medicare established guideline(s) used to determine: a) Medicare and Medicaid provider eligibility b) Medicare outpatient reimbursement rates c) Which diagnoses, signs, or symptoms are reimbursable d) What Medicare reimburses and what should be referred to Medicaid - Correct Answer-C Days in A/R is calculated based on the value of: a) The total accounts receivable on a specific date b) Total anticipated revenue minus expenses c) The time it takes to collect anticipated revenue d) Total cash received to date - Correct Answer-C Patients are contacting hospitals to proactively inquire about costs and fees prior to agreeing to service. The problem for hospitals in providing such information is: a) That hospitals don't want to establish a price without knowing if the patient has insurance and how much reimbursement can be a) Patient Accounts b) Managed Care Contract Staff c) HIM staff d) Case Management - Correct Answer-D What is required for the UB-04/837-I, used by Rural Health Clinics to generate payment from Medicare? a) Revenue codes b) Correct Part A and B procedural codes c) The CMS 1500 Part B attachment d) Medical necessity documentation - Correct Answer-A Before classifying and subsequently writing off an account to financial assistance or bad debt, the hospital must establish policy, define appropriate criteria, implement procedures for identifying and processing accounts: a) Monitor compliance b) Have the account triaged for any partial payment possibilities c) Assist in arranging for a commercial bank loan d) Obtain the patients income tax statements from the prior 2 years - Correct Answer-A For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions: a) Are optional b) Should take place between the patient or guarantor and properly trained provider representatives c) May take place between the patient and discharge planning d) Are focused on verifying required third-party payer information - Correct Answer-B The purpose of a financial report is to: a) Provide a public record, if reqluested b) Present financial information to decision makers c) Prepare tax documents d) Monitor expenses - Correct Answer-B Which statement is an EMTALA (Emergency Medical Treatment and Active Labor Act) violation? a) Registration staff may routinely contact managed are plans for prior authorizations before the patient is seen by the on-duty physician b) Initial registration activities may occur so long as these activities do not delay treatment or suggest that treatment with not be provided to uninsured individuals c) Co-payments may be collected at the time of service once the medical screening and stabilization activities are completed d) Signage must be posted where it can be easily seen and read by patients - Correct Answer-A A claim is denied for the following reasons, EXCEPT: a) The health plan cannot identify the subscriber b) The frequency of service was outside the coverage timeline c) The submitted claim does not have the physicians signature d) The subscriber was not enrolled at the time of service - Correct 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 - Correct 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 - Correct 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 c) The portion of the bill outside of the patient's self-pay d) Transports deemed medically necessary by the attending paramedic-ambulance crew - Correct 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 - Correct 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 - Correct Answer-D Duplicate payments occur: a) When providers re-bill claims based on nonpayment from the initial bill submission b) When service departments do not process charges with the organization's suspense days c) When the payer's coordination of benefits is not captured correctly at the time of patient registration d) When there are other healthcare claims in process and the anticipated deductibles and co-insurance amounts still show open but will be met by the in-process claims - Correct 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 - Correct Answer-A The most common resolution methods for credit balances include all of the following EXCEPT: a) Designate the overpayment for charity care b) Submit the corrected claim to the payer incorporating credits c) Either send a refund or complete a takeback form as directed by the payer d) Determine the correct primary payer and notify incorrect payer of overpayment - Correct Answer-A EFT (electronic funds transfer) is a) An electronic claim submission b) The record of payments in the hospital's accounting system c) An electronic confirmation that a payment is due d) An electronic transfer of funds from payer to payee - Correct Answer-D 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 - Correct 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 c) Pharmacy orders to the ICU have not been entered in the pharmacy system d) Transfer from ICU (intensive care unit) to the Medical/Surgical floor is not reflected in the registration system - Correct Answer-D Which of the following is required for participation in Medicaid? a) Meet income and assets requirements b) Meet a minimum yearly premium c) Be free of chronic conditions d) Obtain a health insurance policy - Correct Answer-A HFMA best practices call for patient financial discussions to be reinforced a) By issuing a new invoice to the patient b) By copying the provider's attorney on a written statement of conversation c) By obtaining some type of collateral d) By changing policies to programs - Correct Answer-B A Medicare Part A benefit period begins: a) With admission as an inpatient b) The first day in which an individual has not been a hospital inpatient not in a skilled nursing facility for the previous 60 days c) Upon the day the coverage premium is paid d) Immediately once authorization for treatment is provided by the health plan - Correct Answer-A If further treatment can only be provided in a hospital setting, the patient's condition cannot be evaluated and/or treated within 24 hours, or if there is not an anticipation of improvement in the patient's condition with 24 hours, the patient a) Will remain in observation for up to 72 hours after which the patient is admitted as an inpatient b) Will be admitted as an inpatient c) Will be discharged and if needed, designated to a priority one outpatient status d) Will have his/her case reviewed by the attending physician, a consulting physician and the primary care physician and a future course of care will then be determined - Correct Answer-B It is important to have high registration quality standards because a) Incomplete registrations will trigger exclusion from Medicare participation b) Incomplete registrations will raise satisfaction scores for the hospital c) Inaccurate registration may cause discharge before full treatment is obtained d) Inaccurate or incomplete patient data will delay payment or cause denials - Correct Answer-D 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" - Correct 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 - Correct 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 - Correct 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- 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 - Correct 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 - Correct 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 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. - Correct 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 - Correct 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 - Correct 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 within the registration process d) The marketing value of such a program - Correct Answer-C Claims with dates of service received later than one calendar year beyond the date of service, will be a) Denied by Medicare d) Eligibility, application process, and nonpayment collection activities - Correct 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 - Correct 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 - Correct Answer-B Under EMTALA (Emergency Medical Treatment and Labor Act) regulations, the provider may not ask about a patient's insurance information if it would delay what? a) Complete course of treatment b) Medical screening and stabilizing treatment c) Admission to observation status d) Transfer to another facility - Correct Answer-B In resolving medical accounts, a law firm may be used as: a) An independent auditor of a financial assistance policy b) Legal counsel to patients regarding financing options c) An independent broker of patient financial assistance from banks d) A substitute for a collection agency - Correct Answer-D The unscheduled "direct" admission represents a patient who: a) Is admitted from a physician's office on an urgent basis b) Arrives at the hospital via ambulance for treatment in the emergency room c) Is an ambulatory patient who collapses in the hospital lobby d) Arrives on the medical helicopter for trauma services - Correct Answer-A In the balance resolution process, providers should: a) Stress to the patient that serious consequences may result from refusal to pay b) Remind the patient of their legal responsibility to pay the balance due c) Ask the patient if he or she would like to receive information about payment options and supportive financial assistance programs d) Tag the patients record for possible financial assistance for bad debt - Correct Answer-C Which of the following in NOT included in the Standardized Quality Measures a) Clinical outcomes b) Patient perceptions c) Health care processes d) Cost of services - Correct Answer-D In the pre-service stage, the requested service is screened for medical necessity, health plan coverage and benefits are verified and: a) Billing authorization is signed by the patient b) The patient signs the consents for treatment c) The patient signs a statement attesting an understanding and acceptance of payment policies d) Pre-authorization are obtained - Correct Answer-D Improving the overall patient experience requires revenue cycle leadership and staff to simultaneously be: a) Clear on policies and consistent in applying the policies b) Careful in screening patient demands c) Monitoring the costs and charges the patient incurs d) Inquisitive, responsive and flexible - Correct 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 - Correct 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 - Correct 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 c) Required for annual Medicare quality reporting forms d) Safeguards the Electronic claims process - Correct 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 - Correct 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 - Correct 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 - Correct Answer-C 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 - Correct 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 - Correct 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 c) The United States department of labor d) The Internal Revenue Service - Correct Answer-D The nightly room charge will be incorrect if the patient's d) Patient through-put - Correct 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 - Correct 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 d) Trigger that the secondary claims can then be prepared. - Correct Answer-C Days in A/R is calculated based on the value of a) Total cash received to date b) The time it takes to collect anticipated revenue c) The total accounts receivable on a specific date d) Total anticipated revenue minus expenses - Correct Answer-C All of the following are forms of hospital payment contracting EXCEPT a) Per diem payment b) Bundled Payment c) Fixed Contracting d) Contracted Rebating - Correct Answer-D The standard claim form used for billing by hospitals, nursing facilities, and other in- patient services is called the a) UB-04 b) 1500 c) COST REPORT d) REMITTANCE NOTICE - Correct Answer-A To maximize the value derived from customer complaints, all consumer complaints should be a) Responded to within two business days b) Tracked and shared to improve the customer experience c) Handled by a specially trained "service recovery" team d) Brought immediately to management's attention - Correct Answer-A The HCAHPS (hospital consumer assessment of healthcare providers and systems) initiative was launched to a) Gather national date on overall trust in the nation's health care system b) Create a national database on physician quality c) Provide a standardized method for evaluating patient's perspective on hospital care. ? d) Provide data for building shared savings reimbursement for quality procedures. - Correct Answer-C Health Plan Contracting Departments do all of the following EXCEPT a) Establish a global reimbursement rate to use with all third-party payer b) Review all managed care contracts for accuracy for loading contract terms into the patient accounting system c) Review payment schemes to ensure that the health plan and provider understand how reimbursements must be calculated d) Review contracts to ensure the appeals process for denied claims is clearly specified - Correct 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 - Correct 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 - Correct Answer-A 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 - Correct 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 - Correct 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 - Correct Answer- A In choosing a setting for pt financial discussions, organizations should first and foremost a) Have processes in place to document the discussions 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 - Correct 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 - Correct 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 - Correct 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 - Correct Answer-A Successful account resolution begins with a) Educating pts on their estimated financial responsibility b) Collecting all deductibles and copayments during the pre-service stage c) Accurate documentation of services d) Pt compliance with the course of treatment - Correct Answer-B An individual enrolled in Medicare who is dissatisfied with the government's claim 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 - Correct 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 - Correct 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 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 12 months - Correct Answer-C Internal controls addressing coding and reimbursement changes are put I place to guard against a) Underpayments b) Denials c) Compliance fraud by upcoding d) Charge master error - Correct Answer-C The pt discharge process begins when a) The physician writes the discharge orders b) Clinical services are completed and pt accounts have all the info necessary to bill c) The physician writes the discharge orders and the third-party payer sign-off on the necessity of the services provided d) Clinical services are completed, pt accounts can generated and accurate bill and there is agreement o the handling of pt financial responsibilities - Correct Answer-A Most major health plans including medicare and Medicaid, offer a) Toll free verification hot lines, staffed around the clock b) Electronic and/or web portal verification c) Pt "verification of benefits" cards d) A grace period for obtaining verification within 72 hours of treatment - Correct Answer-B The physician who wrote the order for an inpatient service and is in charge of the pts treatment during admission is a) The pts personal physician b) The primary care physician c) The attending physician d) The physician pt care director - Correct Answer-C An originating site is a) The location where the pts bill is generated b) The location of the pt at the time the service is provided c) The site that generates reimbursement of a claim d) The location of the medical treatment provider - Correct Answer-B HFMA best practices stipulate that a reasonable attempt should be made to have the financial responsibilities discussion a) As early as possible, before a financial obligation is incurred b) During the registration process c) Before scheduling of services d) No later than the evening of the day of admission - Correct 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 - Correct 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 - Correct 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 c) Inadequate staff training d) Banking transaction errors - Correct 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 - Correct Answer-C The office of inspector general (OIG) publishes a compliance work plan a) Monthly b) Quarterly c) Semi-annually d) Annually - Correct Answer-D What are collection agency fees based on? - Correct Answer-A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - Correct Answer-Birthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - Correct Answer-Case rates What customer service improvements might improve the patient accounts department? - Correct Answer-Holding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - Correct 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? - Correct Answer-Bad debt adjustment What is the initial hospice benefit? - Correct Answer-Two 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - Correct 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? - Correct Answer-Post a late-charge adjustment to the account What form is used to bill Medicare for rural health clinics? - Correct Answer-CMS 1500 What activities are completed when a scheduled pre-registered patient arrives for service? - Correct 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? - Correct Answer-HCPCS (Healthcare Common Procedure Coding system) What results from a denied claim? - Correct Answer-The provider incurs rework and appeal costs Why does the financial counselor need pricing for services? - Correct Answer-To calculate the patient's financial responsibility What type of provider bills third-party payers using CMS 1500 form - Correct Answer- Hospital-based mammography centers How are disputes with nongovernmental payers resolved? - Correct Answer-Appeal conditions specified in the individual payer's contract The important message from Medicare provides beneficiaries with information concerning what? - Correct 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? - Correct 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? - Correct 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? - Correct Answer-120 days passes, but the claim then be withdrawn from the liability carrier What data are required to establish a new MPI entry? - Correct 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? - Correct Answer-Determine the correct payer and notify the incorrect payer of the processing error What do EMTALA regulations require on-call physicians to do? - Correct 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? - Correct Answer-They must be balanced What will cause a CMS 1500 claim to be rejected? - Correct 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? - Correct Answer-The cost of the test how are HCPCS codes and the appropriate modifiers used? - Correct Answer-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? - Correct 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? - Correct Answer-Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - Correct Answer- Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - Correct 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? - Correct Answer-Blue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? - Correct 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? - Correct 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? - Correct Answer-Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? - Correct Answer- Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - Correct Answer-Code of conduct How does utilization review staff use correct insurance information? - Correct Answer- To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - Correct Answer-As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - Correct 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? - Correct Answer-Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - Correct Answer-Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail How are patient reminder calls used? - Correct 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? - Correct 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? - Correct Answer-Sale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - Correct Answer-A condition code What option is an alternative to valid long-term payment plans? - Correct Answer-Bank loans What is an advantage of using a collection agency to collect delinquent patient accounts? - Correct Answer-Collection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? - Correct 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 - Correct Answer-catastrophic charity Discounted fee-for-service - Correct 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 - Correct Answer-Patient status regarding coverage for healthcare insurance benefits First dollar coverage - Correct Answer-A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses Gatekeeping - Correct 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 - Correct Answer-an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - Correct Answer-negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary - Correct 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 - Correct Answer-healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out-of-pocket payments - Correct Answer-Cash payments made by the insured for services not covered by the health insurance plan Pre-admission review - Correct 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 - Correct Answer-A restriction on payments for charges directly resulting from a pre-existing health conditions Same-day admission - Correct 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 - Correct Answer-Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Subrogation - Correct Answer-Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses Subscriber - Correct 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 - Correct Answer-A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery Third-part administrator (TPA) - Correct Answer-Provides services to employers or insurance companies for utilization review, claims payment and benefit design Third-party reimbursement - Correct Answer-A general term used for the healthcare benefit payments - used to identify that for benefit plans there are three parties in the transaction Usual, customary, and reasonable (UCR) - Correct Answer-Health insurance plan reimbursement methodology that limits payment to the lower billed charges, the provider's customary charge, or the prevailing charge for the service in the community Utilization review - Correct Answer-Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Charge - Correct Answer-The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Cost - Correct Answer-The definition of cost varies by party incurring the expense Price - Correct Answer-the total amount a provider expects to be paid by payers and patients for healthcare services Care purchaser - Correct Answer-Individual or entity that contributes to the purchase of healthcare services Payer - Correct Answer-An organization that negotiates or sets rates for provider services, collects revenue through premium payments or tax dollars, processes provider claims for service, and pays provider claims using collected premium or tax revenues Provider - Correct Answer-An entity, organization, or individual that furnishes a healthcare service Out of pocket payment - Correct 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 - Correct 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 - Correct 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? - Correct Answer-Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations FERA - Correct Answer-Fraud Enforcement and Recovery act ESRD - Correct 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? - Correct Answer-Mitigate potential fraud and abuse in the industry-specific key risk areas What is important about an effective corporate compliance program? - Correct 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 - Correct 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? - Correct 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. - Correct Answer-TRUE The OIG has issued compliance guidance/model compliance plans for all of the following entities: - Correct Answer-hospices. physician practices. ambulance providers Providers who are found to be in violation of CMS regulations are subject to: - Correct Answer-Corporate integrity agreements **Follow best practices for communication Which option is NOT a main HFMA Healthcare Dollars & Sense® revenue cycle initiative? - Correct Answer-A. Patient Financial Communications B. Price Transparency C. Medical Account Resolution **D. Process Compliance What is the objective of the HCAHPS initiative? - Correct 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? - Correct Answer-A. Information Technology B. Clinical Services C. Finance **D. Assisted Living Services Which option is NOT a continuum of care provider? - Correct 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? - Correct Answer-**Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines **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. - Correct 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? - Correct Answer-**A. The Correct Coding Initiative (CCI) B. The Advance Beneficiary Notice of Noncoverage (ABN) C. The Medicare Secondary Payer (MSP) D. Modifiers Indicate if the activity is described by the appropriate description of the violation involved: - Correct Answer-True - A staff member receives cash in the mail and does not immediately report the case to the manager for special handling. This is an example of financial misconduct False - A mother sees a charge on her hospital bill for a circumcision for a newborn girl. This is an example of falsifying medical records to boost reimbursement. True - A patient access staff member takes several file folders and highlighters home for personal use. This is an example of theft of property. False - A physician documents a fictitious epidural in a patient's medical record in an effort to receive additional payment. This is an example of miscoding claims True - Several unauthorized claims are sent to a health plan with the wrong procedure code. This is an example of overcharging. What do business/organizational ethics represent? - Correct Answer-**A. Principles and standards by which organizations operate B. A healthcare provider's practices and principles C. An employee's actions influenced by experiences and value system D. The patient privacy standard within healthcare What is the intended outcome of collaborations made through an ACO delivery system? - Correct Answer-**A. To ensure appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients. B. To create cost-containment provisions to reform the healthcare delivery system. C. To reform the healthcare system into a system that rewards greater value, improves the quality of care and increases efficiency in the delivery of services. D. To provide financial incentives to physicians for reporting quality data to CMS. Which of these statements describes the new methodology for the determination of net patient service revenue: - Correct Answer-A. Net patient service revenue is defined as the average payment amount for the payer but not recorded until the end of the month processing is completed. B. Gross patient service revenue is recorded as net patient service revenue until such time as all payments are received. **C. Net patient service revenue is defined as the total incurred charges, less the explicit price concession, less any applicable implicit price concession(s) as applied to the specific portfolio of accounts. D. Net patient service revenue is gross revenue minus any contractual adjustments applicable to the account. Any additional adjustments are not recorded until the account reaches a zero balance. E. Net patient service revenue is the sum of the balances of all charges and payments recorded in the accounting period. What are KPIs? - Correct Answer-A. Benchmarks which are used to compare Key Performance Indicators in an organization to an agreed upon average or expected standard within the same industry. **B. Key performance indicators, which set standards for accounts receivable (A/R) and provide a method of measuring the collection and control of A/R. C. Days in A/R is calculated based on the value of the total accounts receivable on a specific date. D. A component that can divide the accounts receivable into 30, 60, 90, 120 days, and over 120 days categories, based on the date of service/discharge While the highest level of differentiation among patients is scheduled patient vs unscheduled patient, a variety of patient types are routinely identified in both the acute and non-acute settings. Which patient types are typically considered acute care patient types? - Correct Answer-Observation, newborn, Emergency (ED) Accurate identification of the patient is the first step in the scheduling process. Identifiers used in various combination to achieve accurate patient identification include? - Correct Answer-Full legal name, date of birth, sex and social security number Pre-registration is defined as: - Correct Answer-The collection of demographic information, insurance data, financial information, providing reminders, prep information, and identifying the potential need for financial assistance for scheduled patients. Medicare has unique features not found in other health plan programs. It is government sponsored and financed through taxes and general revenue funds. Which of the following statements accurately describes the various Medicare benefits programs: - Correct Answer-Medicare Part A provides benefits for inpatient hospital services, skilled nursing care and home health care; Medicare Part B covers outpatient and professional services, Medicare Part C or Medicare Advantage plans are managed care plans combining Part A and Part B Coverages; and Medicare Part D is the prescription drug coverage benefit. Which of the following statements about Medicaid eligibility is not true? - Correct Answer-Medicaid categories are restricted to children, pregnant women and elderly in nursing homes. Answer-Omission of charges, obsolete or invalid codes, and the omission of required modifiers. Ultimately, the services provided in the healthcare system are reduced to standard codes. The primary types of coding systems currently used in healthcare are: - Correct Answer-ICD-10-CM/ICD-10-PCS; CPT/HCPCS codes There are four code sets that provide health plans with additional information as they process claims. Those code sets are: - Correct Answer-Condition codes, occurrence codes, occurrence span codes and value codes Each type of service has unique billing rules which come into play during the provision of service. For the skilled nursing facility, care is covered if which of the following factors are present: - Correct Answer-The patient required skilled services on a daily basis and those services can only be provided on an inpatient basis in a SNF. DRG's are a system of classifying inpatients on the basis of diagnoses, procedures, and co-morbidities for purposes of payment to hospitals. Each DRG includes: - Correct Answer-A relative weight which is multiplied by the established base payment rate to calculate the reimbursement for a specific DRG. For exceptionally costly cases over a set dollar amount, an outlier payment is added to the calculated payment. PPO networks represent one form of discounting commonly used by commercial payers. The silent PPO represents: - Correct Answer-A discounting scheme whereby health plans apply generic PPO rates to discount a provider's claims, even though there is no contractual arrangement between the silent PPO and the provider. The concept of timely filing of claims is important to providers, payers and patients. Thus, providers are required to comply with timely claim filing rules. Which of the following statements are NOT true about timely filing limitations: - Correct Answer-Payers will waive timely filing denials for claims filed over a year from date of service. What does EMTALA require hospitals to do? - Correct Answer-**A. To provide a medical screening examination and stabilizing treatment to every person presenting at an ED and requesting medical evaluation or treatment. B. To initially triage patients, where a "quick" registration record is generated to specifically allow order entry. C. To complete a standardized form signed by all patients that is used to inform the patient about the admission and conditions which must be agreed upon. D. To confirm information that may be used to identify the patient in the provider's MPI, which includes the patient's full, legal name, SSN, and/or date of birth. In what manner do case managers assist revenue cycle staff? - Correct Answer-A. By reviewing a patient's individual case and recommend treatment changes. B. With monitoring the progression of high resource consumptive cases. C. By estimating how long the patient will be in the hospital and what the expected outcome will be. **D. Providing assistance with written appeals to health plans related to utilization and other care issues. Why is it critical that a chargemaster is reviewed and updated regularly? - Correct Answer-**A. To ensure it supports and represents the services provided within the organization. B. To ensure the most appropriate measure of the utilization of resources. C. So the CPT databases can have the most current and accurate information. D. Because charge descriptions can vary greatly between providers. What is the responsibility of HIM? - Correct Answer-**A. To maintain all patient medical records B. To make information available instantly and securely to authorized users C. To denote the medical procedures performed by a healthcare provider on a patient D. To substantiate health insurance claims filed by the patient, the physician, and the provider What are claim edits? - Correct Answer-A. Various data sources including Medicare and Medicaid bulletins and manuals, individual health plan manuals B. A multi-stakeholder collaboration of more than 130 organizations — providers, health plans, vendors, and government agencies **C. Rules developed to verify the accuracy and completeness of claims based on each health plan's policies D. The submission, receipt, and processing of automated claims, thereby eliminating mail time and reducing data entry time Which statement is NOT a unique billing rule specific to providers? - Correct Answer-A. Overall aggregate payments made to a hospice are subject to a "cap amount", calculated by the MAC at the end of the hospice cap period. B. With the exception of physician services, Medicare reimbursement for hospice care is made at one of four pre-determined rates for each day of hospice care. C. When billing services on a UB-04/837-I, specific CPT codes are collapsed into a single revenue code (520 or 521). **D. A patient may be balance billed for whatever amount the non-contracting physician charges above the health plan's reimbursement amount. Which of the following statements does not apply to billing during the COVID-19 public health emergency: - Correct Answer-A. Hospitals may change a sub-acute unit into an acute care unit without advanced approval from CMS. **B. Telemedicine claims are not payable if the patient conducts the telemedicine visit from home. C. CMS developed the concept of hospitals without walls to increase ICU and med- surge inpatient capacity during the COVID-19 pandemic. D. Cost sharing has been waived for testing for COVID-19 in the ED, physician office, urgent care center or other ambulatory location. What is the sequential order for a Silent PPO scheme? - Correct Answer-The patient's claims is sent to the listed primary insurance carrier The patient's insurance company (a silent PPO) runs the healthcare provider's tax ID number through a PPO discount database or provides a repricing company a copy of the claim After a successful "hit", the claim is "re-priced" based on the PPO discounts that were accessed. After applying the discount, the silent PPO states on the EOB that the healthcare provider agreed to reduce your bill based on your contract with the PPO The medical provider accepts the health plan's statement on the EOB and writes the discount off-never knowing that the discount was invalid. Which concept is NOT a contracted payment model? - Correct Answer-**A. Stop-Loss Provision B. Percentage Discount C. Per Diem Payment D. Capitation Credit balances may be created by any of the following activities except: - Correct Answer-Credits to pharmacy charges posted before the claim final bills Which of the following statements represent common reasons for inpatient claim denials? - Correct Answer-Failure to obtain a required pre-authorization; failure to complete a continued stay authorization and services provided which were not medically necessary. A 68 year old patient, a Medicare beneficiary, was in a car accident. A medical insurance claim was filed with the auto insurance carrier. Six months later this claim remains unpaid. How can the provider pursue payment from Medicare? - Correct Answer-The provider must first bill the auto insurer; however, after a period of 120 days, if the claim remains unpaid, the provider may cancel the liability claim and bill Medicare. The difference between bad debt and financial assistance (charity) is: - Correct Answer- Bad debt represents a refusal to pay; charity represents an inability to pay In order to qualify for financial assistance, a patient or guarantor should: - Correct Answer-Provide the following documents: prior year tax return, employment check stubs from the prior three months and bank statements for the prior three months. **C. The employment of staff who have documented experience working in financial areas of health care. D. The high turnover rate for entry level employees. Agency fees are: - Correct Answer-A. Paid by patients. **B. The cost to the provider for collection agency monies offset by the return on baddebt accounts. C. Only reported annually to the provider. D. Waived for accounts aged greater than one year from date of service. The correct way to handle the retention and payment of agency fees is: - Correct Answer-A. The agency provides an annual settlement of monies received by the health care provider and the agency. B. Compare estimated collection costs to actual costs incurred. C. Validate bank deposits weekly as funds are received from the agency. **D. Follow the contractual agreement between the agency and the provider as to how monies sent to the agency will be handled. Patient relations include: - Correct Answer-**A. The ability to sensitively deal with patients or individuals while managing collection efficiency. B. Applying hard-core techniques to collect monies owed regardless of what the patient or individual states during the call. C. Ignoring all patient complaint calls. D. Referring all patient complaint calls to the healthcare provider. Collection agency reports should be provided: - Correct Answer-A. Whenever staff have the time to generate them. B. Whenever an account is cancelled. **C. In at least two formats regarding accounts assigned on a routine basis. D. As needed to prove recovery rates. Collection results are: - Correct Answer-A. Always guaranteed by the collection agency. **B. Accurately calculated to demonstrate the actual recovery percentage rate. C. Calculated using agency's private formula. D. Never reported except during contract negotiations. Which option is NOT a HFMA best practice? - Correct Answer-A. Coordinate the resolution of bad debt accounts with a law firm B. Establish policies and ensure that they are followed NOT - C. Coordinate account resolution activities with business affiliates D. Report back to credit bureaus when an account is resolved True or False: The following statement represents an advantage of outsourcing: Access to qualified staff - Correct Answer-**True False True or False: The following statement represents an advantage of outsourcing: Vendor absorbs some financial risk based on "efficiency" factor - Correct Answer-**True False True or False: The following statement represents an advantage of outsourcing: Impact on direct control of accounts receivable - Correct Answer-True **False True or False: The following statement represents an advantage of outsourcing: Capitalizes on the economies of scale - Correct Answer-**True False True or False: The following statement represents an advantage of outsourcing: Limits internal staffing requirements - Correct Answer-**True False True or False: The following statement represents an advantage of outsourcing: Impact on customer service - Correct Answer-True **False True or False: The following statement represents an advantage of outsourcing: Legal impact if vendor represents themselves as provider employees - Correct Answer- True **False True or False: The following statement represents an advantage of outsourcing: Ineffective vendor results in increased costs - Correct Answer-True **False ABC Hospital has experienced a 16% increase in new patients over the past 6 months. The hospital is understaffed in its insurance claim and payment processing department and cannot handle this increase in work load. It is considering hiring an outsourcing vendor to assist. What are the steps that the hospital needs to take to establish and ensure a successful vendor relationship? - Correct Answer-**A. Distribute a RFP to solicit vendor capabilities, evaluate vendor's expertise to provide outsourcing services, visit vendor locations, perform vendor reference checks, talk with vendor clients, interview vendor employees to assess experience level. B. Evaluate vendor's expertise in providing outsourcing services, visit vendor locations, interview vendor employees to assess expertise level. Which function within the revenue cycle is NOT a good candidate for outsourcing? - Correct Answer-**A. Health Care Patient Services B. Patient Accounting C. Patient Access D. Health Information Management