Healthcare Insurance Terminology and Concepts, Exams of Nursing

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CRCR EXAM 2024/2025 WITH 100% ACCURATE SOLUTIONS What are collection agency fees based on? - Precise Answer ✔✔A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - Precise Answer ✔✔Birthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - Precise Answer ✔✔Case rates What customer service improvements might improve the patient accounts department? - Precise Answer ✔✔Holding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - Precise 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? - Precise Answer ✔✔Bad debt adjustment What is the initial hospice benefit? - Precise Answer ✔✔Two 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - Precise 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? - Precise 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 - Precise Answer ✔✔They are not being processed in a timely manner What is an advantage of a preregistration program? - Precise Answer ✔✔It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - Precise Answer ✔✔Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - Precise Answer ✔✔Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts When an undue delay of payment results from a dispute between the patient and the third party payer, who is responsible for payment? - Precise 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: - Precise 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? - Precise Answer ✔✔Access their information and perform functions on-line What date is required on all CMS 1500 claim forms? - Precise Answer ✔✔onset date of current illness What does scheduling allow provider staff to do - Precise Answer ✔✔Review appropriateness of the service request What code is used to report the provider's most common semiprivate room rate? - Precise Answer ✔✔Condition code Regulations and requirements for coding accountable care organizations, which allows providers to begin creating these organizations, were finalized in: - Precise Answer ✔✔2012 What is a primary responsibility of the Recover Audit Contractor? - Precise Answer ✔✔To correctly identify proper payments for Medicare Part A & B claims How must providers handle credit balances? - Precise Answer ✔✔Comply with state statutes concerning reporting credit balance Insurance verification results in what? - Precise Answer ✔✔The accurate identification of the patient's eligibility and benefits What form is used to bill Medicare for rural health clinics? - Precise Answer ✔✔CMS 1500 What activities are completed when a scheduled pre-registered patient arrives for service? - Precise 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? - Precise Answer ✔✔HCPCS (Healthcare Common Procedure Coding system) What results from a denied claim? - Precise Answer ✔✔The provider incurs rework and appeal costs Why does the financial counselor need pricing for services? - Precise Answer ✔✔To calculate the patient's financial responsibility What type of provider bills third-party payers using CMS 1500 form - Precise Answer ✔✔Hospital-based mammography centers How are disputes with nongovernmental payers resolved? - Precise Answer ✔✔Appeal conditions specified in the individual payer's contract The important message from Medicare provides beneficiaries with information concerning what? - Precise 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? - Precise 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? - Precise 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? - Precise Answer ✔✔120 days passes, but the claim then be withdrawn from the liability carrier What data are required to establish a new MPI entry? - Precise Answer ✔✔The patient's full legal name, date of birth, and sex In services lines such as cardiology or orthopedics, what does the case- rate payment methodology allow providers to do? - Precise Answer ✔✔Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? - Precise Answer ✔✔Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - Precise Answer ✔✔Code of conduct How does utilization review staff use correct insurance information? - Precise Answer ✔✔To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - Precise Answer ✔✔As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - Precise 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? - Precise Answer ✔✔Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - Precise Answer ✔✔Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail How are patient reminder calls used? - Precise 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? - Precise 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? - Precise Answer ✔✔Sale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - Precise Answer ✔✔A condition code What option is an alternative to valid long-term payment plans? - Precise Answer ✔✔Bank loans What is an advantage of using a collection agency to collect delinquent patient accounts? - Precise Answer ✔✔Collection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? - Precise 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 - Precise Answer ✔✔catastrophic charity What happens when a patient receives non-emergent services from and out-of-network provider? - Precise Answer ✔✔Patient payment responsibility is higher Every patient who is new to the healthcare provider must be offered what? - Precise Answer ✔✔A printed copy of the provider's privacy notice How may a collection agency demonstrate its performance? - Precise 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? - Precise 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? - Precise Answer ✔✔The UB-04 and the CMS 1500 What is a benefit of electronic claims processing? - Precise Answer ✔✔Providers can electronically view patient's eligibility What does Medicare Part D provide coverage for? - Precise Answer ✔✔Prescription drugs What are some core elements of a board-approved financial policy - Precise Answer ✔✔Charity care, payment methods, and installment payment guidelines What circumstance would result in an incorrect nightly room charge? - Precise 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? - Precise Answer ✔✔Does not include required modifiers Access - Precise Answer ✔✔An individual's ability to obtain medical services on a timely and financially acceptable level Administrative Services Only (ASO) - Precise Answer ✔✔Usually contracted administrative services to a self-insured health plan Case management - Precise 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 - Precise Answer ✔✔A demand by an insured person for the benefits provided by the group contract Coordination of benefits (COB) - Precise 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 - Precise 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 - Precise Answer ✔✔Patient status regarding coverage for healthcare insurance benefits First dollar coverage - Precise Answer ✔✔A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses Gatekeeping - Precise 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 - Precise Answer ✔✔an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - Precise Answer ✔✔negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary - Precise 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 - Precise Answer ✔✔healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out-of-pocket payments - Precise Answer ✔✔Cash payments made by the insured for services not covered by the health insurance plan Pre-admission review - Precise 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 - Precise Answer ✔✔A restriction on payments for charges directly resulting from a pre-existing health conditions Provider - Precise Answer ✔✔An entity, organization, or individual that furnishes a healthcare service Out of pocket payment - Precise 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 - Precise 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 - Precise 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? - Precise Answer ✔✔Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations FERA - Precise Answer ✔✔Fraud Enforcement and Recovery act ESRD - Precise 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? - Precise Answer ✔✔Mitigate potential fraud and abuse in the industry-specific key risk areas What is important about an effective corporate compliance program? - Precise 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 - Precise 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? - Precise 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. - Precise Answer ✔✔TRUE The OIG has issued compliance guidance/model compliance plans for all of the following entities: - Precise Answer ✔✔hospices. physician practices. ambulance providers Providers who are found to be in violation of CMS regulations are subject to: - Precise Answer ✔✔Corporate integrity agreements What MSP situation requires LGHP - Precise 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 - Precise 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 that may arise in the course of treatment d) Their reluctance to share proprietary information - Precise Answer ✔✔B Across all care settings, if a patient consents to a financial discussion during a medical encounter to expedite discharge, the HFMA best practice is to: a) Make sure that the attending staff can answer questions and assist in obtaining required patient financial data b) Have a patient financial responsibilities kit ready for the patient, containing all of the required registration forms and instructions c) Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow d) Decline such request as finance discussions can disrupt patient care and patient flow - Precise Answer ✔✔C A comprehensive "Compliance Program" is defined as a) Annual legal audit and review for adherence to regulations b) Educating staff on regulations c) Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met d) The development of operational policies that correspond to regulations - Precise 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 - Precise 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 - Precise 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) MSO b) HMO c) PPO d) GPO - Precise 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 - Precise Answer ✔✔A The core financial activities resolved within patient access include: d) Obtain the patients income tax statements from the prior 2 years - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise Answer ✔✔C 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 - Precise 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 - Precise Answer ✔✔D Revenue cycle activities occurring at the point-of-service include all of the following EXCEPT: a) The monitoring of charges b) The provision of case management and discharge planning services c) Providing charges to the third-party payer as they are incurred d) The generation of charges - Precise Answer ✔✔C Medicare beneficiaries remain in the same "benefit period" a) Up to hospitalization discharge b) Until the beneficiary is "hospitalization and/or skilled nursing facility-free" for 60 consecutive days c) Each calendar year d) Up to 60 days - Precise Answer ✔✔B Key Performance Indicators (KPIs) set standards for accounts receivables (A/R) and a) Provide evidence of financial status b) Provide a method of measuring the collection and control of A/R c) Establish productivity targets d) Make allowance for accurate revenue forecasting - Precise Answer ✔✔B Recognizing that health coverage is complicated and not all patients are able to navigate this terrain, HFMA best practices specify that a) The patient accounts staff have someone assigned to research coverage on behalf of patients b) Patients should be given the opportunity to request a patient advocate, family member, or other designee to help them in these discussions c) Patient coverage education may need to be provided by the health plan d) A representative of the health plan be included in the patient financial responsibilities discussion - Precise 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 - Precise 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 c) Collect patient's self-pay and deductibles in the first encounter d) Assist patients in understanding their insurance coverage and their financial obligation - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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" - Precise Answer ✔✔D Room and bed charges are typically posted a) From case management reports generated for contracted payers 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 - Precise 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 - Precise 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 - Precise Answer ✔✔C Claims with dates of service received later than one calendar year beyond the date of service, will be a) Denied by Medicare b) The provider's responsibility but can be deemed charity care c) Fully paid with interest d) The full responsibility of the patient. - Precise Answer ✔✔A This concept encompasses all activities required to send a request for payment to a third-party health plan for payment of benefits a) Third-party invoicing b) Account resolution c) Claims processing d) Billing - Precise Answer ✔✔C The ACO investment model will test the use of pre-paid shared savings to a) Raise quality ratings in designated hospitals. b) Encourage new ACOs to form in rural and underserved areas c) Attract physicians to participate in the ACO payment system d) Invest in treatment protocols that reduce costs to Medicare - Precise Answer ✔✔B Chapter 13 Bankruptcy, debtor rehabilitation, is a court proceeding a) That establishes a payment priority order to creditors' claims b) That classifies the debtor as eligible for government financial assistance for housing, medical treatment and food as debts are paid c) That creates a clear court-supervised payment accountability plan going forward d) That reorganizes a debtor's holdings and instructs creditors to look to the debtor's future earnings for payment - Precise Answer ✔✔D HFMA's patient financial communication best practices specify that patients should be told about the types of services provided and a) A satisfaction survey regarding clinical service providers b) The price of service to their covering health plan c) The service providers that typically participate in the service, e.g., radiologists, pathologists, etc. b) Current medical needs c) The likelihood of an adverse event occurring to the patient d) The patient's medical history - Precise 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 - Precise Answer ✔✔D 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise Answer ✔✔C 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise Answer ✔✔D The nightly room charge will be incorrect if the patient's a) Transfer from ICU to the Medical/Surgical floor is not reflected in the registration system. b) Pharmacy orders to the ICU have not been entered into the pharmacy system c) Condition has not been discussed during the shift change report meeting d) Discharge for the next day has not been charted - Precise Answer ✔✔A With any remaining open balances, after insurance payments have been posted, the account financial liability is a) Written off as bad debt b) Potentially transferred to the patient 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 - Precise 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 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 - Precise 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 - Precise 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 pay off the largest claims first. All claims are paid some portions of the amount owed. - Precise 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 - Precise 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 - Precise 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. - Precise 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 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise Answer ✔✔B b) The patient accounts staff have someone assigned to research coverage on behalf of pts c) Pts should be given the opportunity to request a pt advocate, family member or other designee to help them In these discussions d) Pt coverage education may need to be provided by the health plan - Precise Answer ✔✔C Once the price is estimated in the pre-service stage, a provider's financial best practice is to a) Allow the pt time to compare prices with other providers b) Have another employee double check the price estimate c) Lock-in the prices d) Explain to the pt their financial responsibility and to determine the plan for payment - Precise 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 - Precise 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 - Precise 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 - Precise Answer ✔✔C 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 - Precise 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 - Precise 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 - Precise Answer ✔✔B 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 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise 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 - Precise Answer ✔✔C What core financial activities are resolved within patient access? - Precise Answer ✔✔Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts What statement applies to the scheduled outpatient? - Precise Answer ✔✔The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - Precise 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? - Precise Answer ✔✔Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - Precise 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$? - Precise Answer ✔✔When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - Precise 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? - Precise 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? - Precise Answer ✔✔Disclosure rules for consumer credit sales and consumer loans What is a principal diagnosis? - Precise Answer ✔✔Primary reason for the patient's admission Collecting patient liability dollars after service leads to what? - Precise Answer ✔✔Lower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - Precise 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? - Precise Answer ✔✔Inpatient care What code indicates the disposition of the patient at the conclusion of service? - Precise Answer ✔✔Patient discharge status code What are hospitals required to do for Medicare credit balance accounts? - Precise 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? - Precise 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: - Precise 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? - Precise Answer ✔✔Access their information and perform functions on-line What date is required on all CMS 1500 claim forms? - Precise Answer ✔✔onset date of current illness What does scheduling allow provider staff to do - Precise Answer ✔✔Review appropriateness of the service request What code is used to report the provider's most common semiprivate room rate? - Precise Answer ✔✔Condition code 90. MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - Precise Answer ✔✔120 days passes, but the claim then be withdrawn from the liability carrier What data are required to establish a new MPI entry? - Precise 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? - Precise Answer ✔✔Determine the correct payer and notify the incorrect payer of the processing error What do EMTALA regulations require on-call physicians to do? - Precise 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? - Precise Answer ✔✔They must be balanced What will cause a CMS 1500 claim to be rejected? - Precise 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? - Precise Answer ✔✔The cost of the test how are HCPCS codes and the appropriate modifiers used? - Precise 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? - Precise 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? - Precise Answer ✔✔Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - Precise Answer ✔✔Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - Precise 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? - Precise Answer ✔✔Blue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? - Precise 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? - Precise 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? - Precise Answer ✔✔Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? - Precise Answer ✔✔Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - Precise Answer ✔✔Code of conduct How does utilization review staff use correct insurance information? - Precise Answer ✔✔To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - Precise Answer ✔✔As a substitute for an inpatient admission 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? - Precise 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? - Precise 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? - Precise Answer ✔✔Obtain the required demographic and insurance information before services are rendered what protocol was developed through the Patient Friendly Billing Project? - Precise 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? - Precise Answer ✔✔Ask if the patient's current services was accident related What is a valid reason for a payer to delay a claim? - Precise 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 - Precise Answer ✔✔They must be combined with the inpatient bill and paid under the MS-DRG system What do large adjustments require? - Precise Answer ✔✔Manager-level approval What items are valid identifiers to establish a patient's identification? - Precise Answer ✔✔Photo identification, date of birth, and social security number What must a provider do to qualify an account as a Medicare bad debts? - Precise 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? - Precise Answer ✔✔Site-of-service limitation What is an example of an outcome of the Patient Friendly Billing Project? - Precise Answer ✔✔Redesigned patient billing statements using patient-friendly language What statement describes the APC (Ambulatory payment classification) system? - Precise Answer ✔✔APC rates are calculated on a national basis and are wage-adjusted by geographic region What is a benefit of insurance verification? - Precise Answer ✔✔Pre- certification or pre-authorization requirements are confirmed What is an effective tool to help staff collect payments at the time of service? - Precise Answer ✔✔Develop scripts for the process of requesting payments What is a benefit of electronic claims processing? - Precise Answer ✔✔Providers can electronically view patient's eligibility What does Medicare Part D provide coverage for? - Precise Answer ✔✔Prescription drugs What are some core elements of a board-approved financial policy - Precise Answer ✔✔Charity care, payment methods, and installment payment guidelines What circumstance would result in an incorrect nightly room charge? - Precise 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? - Precise Answer ✔✔Does not include required modifiers Access - Precise Answer ✔✔An individual's ability to obtain medical services on a timely and financially acceptable level Pre-existing condition limitation - Precise Answer ✔✔A restriction on payments for charges directly resulting from a pre-existing health conditions Same-day admission - Precise 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 - Precise Answer ✔✔Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Subrogation - Precise Answer ✔✔Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses Subscriber - Precise 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 - Precise Answer ✔✔A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery Third-part administrator (TPA) - Precise Answer ✔✔Provides services to employers or insurance companies for utilization review, claims payment and benefit design Third-party reimbursement - Precise 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) - Precise 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 - Precise Answer ✔✔Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Charge - Precise Answer ✔✔The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Cost - Precise Answer ✔✔The definition of cost varies by party incurring the expense Price - Precise Answer ✔✔the total amount a provider expects to be paid by payers and patients for healthcare services Care purchaser - Precise Answer ✔✔Individual or entity that contributes to the purchase of healthcare services Payer - Precise 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 - Precise Answer ✔✔An entity, organization, or individual that furnishes a healthcare service Out of pocket payment - Precise 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 - Precise 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 - Precise 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? - Precise Answer ✔✔Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations