Healthcare Insurance Terminology and Concepts, Exams of Nursing

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CRCR Exam Prep, Certified Revenue

Cycle Representative - (2023-2024)

Correct 100%.

What are collection agency fees based on? - ANSWERSA percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - ANSWERSBirthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - ANSWERSCase rates What customer service improvements might improve the patient accounts department?

• ANSWERSHolding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - ANSWERSInform 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? - ANSWERSBad debt adjustment What is the initial hospice benefit? - ANSWERSTwo 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - ANSWERSIf 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? - ANSWERSPost 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 - ANSWERSThey are not being processed in a timely manner What is an advantage of a preregistration program? - ANSWERSIt reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - ANSWERSMedically unnecessary services and custodial care

What core financial activities are resolved within patient access? - ANSWERSScheduling, insurance verification, discharge processing, and payment of point-of-service receipts What statement applies to the scheduled outpatient? - ANSWERSThe services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - ANSWERSComparing 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? - ANSWERSObservation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - ANSWERSMedically 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$? - ANSWERSWhen the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - ANSWERSUnscheduled patients If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - ANSWERSNeither enrolled not entitled to benefits Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what? - ANSWERSDisclosure rules for consumer credit sales and consumer loans What is a principal diagnosis? - ANSWERSPrimary reason for the patient's admission Collecting patient liability dollars after service leads to what? - ANSWERSLower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - ANSWERS50% 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? - ANSWERSInpatient care What code indicates the disposition of the patient at the conclusion of service? - ANSWERSPatient discharge status code

What are hospitals required to do for Medicare credit balance accounts? - ANSWERSThey 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? - ANSWERSPatient Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: - ANSWERSA valid CPT or HCPCS code With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what? - ANSWERSAccess their information and perform functions on-line What date is required on all CMS 1500 claim forms? - ANSWERSonset date of current illness What does scheduling allow provider staff to do - ANSWERSReview appropriateness of the service request What code is used to report the provider's most common semiprivate room rate? - ANSWERSCondition code Regulations and requirements for coding accountable care organizations, which allows providers to begin creating these organizations, were finalized in: - ANSWERS What is a primary responsibility of the Recover Audit Contractor? - ANSWERSTo correctly identify proper payments for Medicare Part A & B claims How must providers handle credit balances? - ANSWERSComply with state statutes concerning reporting credit balance Insurance verification results in what? - ANSWERSThe accurate identification of the patient's eligibility and benefits What form is used to bill Medicare for rural health clinics? - ANSWERSCMS 1500 What activities are completed when a scheduled pre-registered patient arrives for service? - ANSWERSRegistering 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? - ANSWERSHCPCS (Healthcare Common Procedure Coding system)

What results from a denied claim? - ANSWERSThe provider incurs rework and appeal costs Why does the financial counselor need pricing for services? - ANSWERSTo calculate the patient's financial responsibility What type of provider bills third-party payers using CMS 1500 form - ANSWERSHospital-based mammography centers How are disputes with nongovernmental payers resolved? - ANSWERSAppeal conditions specified in the individual payer's contract The important message from Medicare provides beneficiaries with information concerning what? - ANSWERSRight 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? - ANSWERSTo 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? - ANSWERSSubmit interim bills to the Medicare program.

90. MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - ANSWERS120 days passes, but the claim then be withdrawn from the liability carrier What data are required to establish a new MPI entry? - ANSWERSThe 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? - ANSWERSDetermine the correct payer and notify the incorrect payer of the processing error What do EMTALA regulations require on-call physicians to do? - ANSWERSPersonally 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? - ANSWERSThey must be balanced What will cause a CMS 1500 claim to be rejected? - ANSWERSThe 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? - ANSWERSThe cost of the test

how are HCPCS codes and the appropriate modifiers used? - ANSWERSTo 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? - ANSWERSDiagnostic 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? - ANSWERSPatient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - ANSWERSProspectively set rates for inpatient and outpatient services What do the MSP disability rules require? - ANSWERSThat 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? - ANSWERSBlue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? - ANSWERSIt 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? - ANSWERSWarn 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? - ANSWERSReceive a fixed for specific procedures What will comprehensive patient access processing accomplish? - ANSWERSMinimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - ANSWERSCode of conduct How does utilization review staff use correct insurance information? - ANSWERSTo obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - ANSWERSAs a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - ANSWERSThe 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? - ANSWERSRedirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - ANSWERSSend high- dollar hard-copy claims with required attachments by overnight mail or registered mail How are patient reminder calls used? - ANSWERSTo 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? - ANSWERSWrite off the account to the contractual adjustment account According to the Department of Health and Human Services guidelines, what is NOT considered income? - ANSWERSSale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - ANSWERSA condition code What option is an alternative to valid long-term payment plans? - ANSWERSBank loans What is an advantage of using a collection agency to collect delinquent patient accounts? - ANSWERSCollection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? - ANSWERSrevenue 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 - ANSWERScatastrophic charity What happens when a patient receives non-emergent services from and out-of-network provider? - ANSWERSPatient payment responsibility is higher Every patient who is new to the healthcare provider must be offered what? - ANSWERSA printed copy of the provider's privacy notice How may a collection agency demonstrate its performance? - ANSWERSCalculate 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? - ANSWERSIt 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? - ANSWERSThe UB-04 and the CMS 1500

Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information? - ANSWERSObtain the required demographic and insurance information before services are rendered what protocol was developed through the Patient Friendly Billing Project? - ANSWERSProvide 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? - ANSWERSAsk if the patient's current services was accident related What is a valid reason for a payer to delay a claim? - ANSWERSFailure 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 - ANSWERSThey must be combined with the inpatient bill and paid under the MS-DRG system What do large adjustments require? - ANSWERSManager-level approval What items are valid identifiers to establish a patient's identification? - ANSWERSPhoto identification, date of birth, and social security number What must a provider do to qualify an account as a Medicare bad debts? - ANSWERSPursue 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? - ANSWERSSite-of-service limitation What is an example of an outcome of the Patient Friendly Billing Project? - ANSWERSRedesigned patient billing statements using patient-friendly language What statement describes the APC (Ambulatory payment classification) system? - ANSWERSAPC rates are calculated on a national basis and are wage-adjusted by geographic region What is a benefit of insurance verification? - ANSWERSPre-certification or pre- authorization requirements are confirmed What is an effective tool to help staff collect payments at the time of service? - ANSWERSDevelop scripts for the process of requesting payments

What is a benefit of electronic claims processing? - ANSWERSProviders can electronically view patient's eligibility What does Medicare Part D provide coverage for? - ANSWERSPrescription drugs What are some core elements of a board-approved financial policy - ANSWERSCharity care, payment methods, and installment payment guidelines What circumstance would result in an incorrect nightly room charge? - ANSWERSIf 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? - ANSWERSDoes not include required modifiers Access - ANSWERSAn individual's ability to obtain medical services on a timely and financially acceptable level Administrative Services Only (ASO) - ANSWERSUsually contracted administrative services to a self-insured health plan Case management - ANSWERSThe 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 - ANSWERSA demand by an insured person for the benefits provided by the group contract Coordination of benefits (COB) - ANSWERSa 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 - ANSWERSA reimbursement methodology whereby a provider agrees to provide service on a fee for service basis, but the fees are discounted by certain packages Eligibility - ANSWERSPatient status regarding coverage for healthcare insurance benefits First dollar coverage - ANSWERSA healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses Gatekeeping - ANSWERSA 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 - ANSWERSan insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - ANSWERSnegotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary - ANSWERSHealthcare services that are required to preserve or maintain a person's health status in accordance with medical practice standards Out-of-area benefits - ANSWERShealthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out-of-pocket payments - ANSWERSCash payments made by the insured for services not covered by the health insurance plan Pre-admission review - ANSWERSthe practice of reviewing requests for inpatient admission before the patient is admitted to ensure that the admission is medically necesary Pre-existing condition limitation - ANSWERSA restriction on payments for charges directly resulting from a pre-existing health conditions Same-day admission - ANSWERSA 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 - ANSWERSLarge employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Subrogation - ANSWERSSeeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses Subscriber - ANSWERSAn employer, a union, or an association that contracts with an insurance company for the healthcare plan it offers to eligible employees Sub-specialist - ANSWERSA healthcare professional who is recognized to have expertise in a specialty of medicine or surgery Third-part administrator (TPA) - ANSWERSProvides services to employers or insurance companies for utilization review, claims payment and benefit design Third-party reimbursement - ANSWERSA 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) - ANSWERSHealth 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 - ANSWERSReview conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Charge - ANSWERSThe dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Cost - ANSWERSThe definition of cost varies by party incurring the expense Price - ANSWERSthe total amount a provider expects to be paid by payers and patients for healthcare services Care purchaser - ANSWERSIndividual or entity that contributes to the purchase of healthcare services Payer - ANSWERSAn 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 - ANSWERSAn entity, organization, or individual that furnishes a healthcare service Out of pocket payment - ANSWERSThe portion of the total payment for medical services and treatment for which the patient is responsible, including copayments, coinsurance, and deductibles Price transparency - ANSWERSIn 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 - ANSWERSThe 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? - ANSWERSHuman resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations FERA - ANSWERSFraud Enforcement and Recovery act

ESRD - ANSWERSEnd-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? - ANSWERSMitigate potential fraud and abuse in the industry-specific key risk areas What is important about an effective corporate compliance program? - ANSWERSA 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 - ANSWERSChief 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? - ANSWERSWork-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. - ANSWERSTRUE The OIG has issued compliance guidance/model compliance plans for all of the following entities: - ANSWERShospices. physician practices. ambulance providers Providers who are found to be in violation of CMS regulations are subject to: - ANSWERSCorporate integrity agreements What MSP situation requires LGHP - ANSWERSDisability 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 - ANSWERSD 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) - ANSWERSB

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 - ANSWERSA 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 - ANSWERSA 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 - ANSWERSC 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 - ANSWERSC 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 expected b) The fact that charge master lists the total charge, not net charges that reflect charges after a payer's contractual adjustment c) That hospitals don't want to be put in the position of "guaranteeing" price without having room for additional charges that may arise in the course of treatment d) Their reluctance to share proprietary information - ANSWERSB

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 - ANSWERSC 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 - ANSWERSC 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 - ANSWERSB 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 - ANSWERSA 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 - ANSWERSB

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 - ANSWERSA The core financial activities resolved within patient access include: a) Scheduling, pre-registration, insurance verification and managed care processing b) Scheduling, insurance verification, clinical discharge processing and payment posting of point of service receipts c) Scheduling, registration, charge entry and managed care processing d) Scheduling, pre-registration, registration, medical necessity screening and patient refunds - ANSWERSA Which of the following is NOT contained in a collection agency agreement? a) A clear understanding that the provider retains ownership of any outsourced activities b) Specific language as to who will pay legal fees, if needed c) An annual renewal clause d) A mutual hold-harmless clause - ANSWERSD Maintaining routine contact with the health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of: a) Patient Accounts b) Managed Care Contract Staff c) HIM staff d) Case Management - ANSWERSD 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 - ANSWERSA 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 - ANSWERSA 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 - ANSWERSB 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 - ANSWERSB 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 - ANSWERSA 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 - ANSWERSC 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 - ANSWERSD 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 - ANSWERS???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 - ANSWERSC 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 - ANSWERSA 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 - ANSWERSD 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 - ANSWERSa 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 - ANSWERSA 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 - ANSWERSA 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 - ANSWERSD 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 - ANSWERSC

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 - ANSWERSB 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 - ANSWERSB 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 - ANSWERSB 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 - ANSWERSD Once the price is estimated in the pre-service stage, a provider's financial best practice is to a) Explain to the patient their financial responsibility and to determine the plan for payment b) Allow the patient time to compare prices with other providers

c) Lock-in the prices d) Have another employee double check the price estimate - ANSWERSA What type of account adjustment results from the patient's unwillingness to pay a self- pay balance? a) Charity adjustment b) Bad debt adjustment c) Contractual adjustment d) Administrative adjustment - ANSWERSB All of the following are conditions that disqualify a procedure or service from being paid for by Medicare EXCEPT a) Medically unnecessary b) Not delivered in a Medicare licensed care setting c) Offered in an outpatient setting d) Services and procedures that are custodial in nature - ANSWERSD All of the following are forms of hospital payment contracting EXCEPT a) Contracted Rebating b) Per Diem Payment c) Fixed Contracting d) Bundled Payment - ANSWERSA Overall aggregate payments made to a hospice are subject to a computed "cap amount" calculated by: a) The Center for Medicare and Medicaid Services (CMS) b) Each state's Medicaid plan c) Medicare d) The Medicare Administrative Contractor (MAC) at the end of the hospice cap period - ANSWERSD With the advent of the Affordable Care Act Health Insurance Marketplaces and the expansion of Medicaid in some states, it is more important than ever for hospitals to a) Reschedule the visit for non-payment of a prior balance b) Strictly limit charity care and bad-debt c) Collect patient's self-pay and deductibles in the first encounter d) Assist patients in understanding their insurance coverage and their financial obligation - ANSWERSD 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 - ANSWERSD 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 - ANSWERSA 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 - ANSWERSB 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 - ANSWERSA 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 - ANSWERSB 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 - ANSWERSD 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" - ANSWERSD 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 - ANSWERSD 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 - ANSWERSC 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 - ANSWERSC 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 - ANSWERSD

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. - ANSWERSC 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 - ANSWERSC 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 - ANSWERSB 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 - ANSWERSC 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. - ANSWERSA 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 - ANSWERSC 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 - ANSWERSB 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 - ANSWERSD 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. d) An expiration of why a specific service is not provided - ANSWERSC The important Message from Medicare provides beneficiaries information concerning their a) Understanding of billing issues and the deductibles and/or co-insurance due for the current visit b) Right to refuse to use lifetime reserve days for the current stay c) Right to appeal a discharge decision if the patient disagrees with the plan d) Obligation to reimburse the hospital for any services not covered by the Medicare program - ANSWERSC All of the following are potential causes of credit balances EXCEPT a) Duplicate payments b) Primary and secondary payers both paying as primary c) Inaccurate upfront collections based on incorrect liability estimates d) A patient's choice to build up a credit against future medical bills - ANSWERSD Medicare Part B has an annual deductible, and the beneficiary is responsible for

a) A co-insurance payment for all Part B covered services b) Physicians office fees c) Tests outside of an inpatient setting d) Prescriptions - ANSWERSA The importance of medical records being maintained by HIM is that the patient records a) Are the primary source for clinical data required for reimbursement by health plans and liability payers b) Are the strongest evidence and defense in the event of a Medicare audit c) Are evidence used in assessing the quality of care d) Are the evidence cited in quality review - ANSWERSA A decision on whether a patient should be admitted as an inpatient or become an outpatient observation patient requires medical judgments based on all of the following EXCEPT a) The patient's home care coverage b) Current medical needs c) The likelihood of an adverse event occurring to the patient d) The patient's medical history - ANSWERSA 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 - ANSWERSD 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 - ANSWERSD 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 - ANSWERSD

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 - ANSWERSB 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 - ANSWERSB 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 - ANSWERSD 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 - ANSWERSA 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 - ANSWERSC 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 - ANSWERSD 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