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CRCR EXAM MULTIPLE CHOICE (Prep) Certified Revenue Cycle Representative Questions with Verified Answers 2024 What are collection agency fees based on? - Correct Answer -A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - Correct Answer -Birthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - Correct Answer - Case rates What customer service improvements might improve the patient accounts department? - Correct Answer -Holding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - Correct Answer -Inform a Medicare beneficiary that Medicare may not pay for the order or service What type of account adjustment results from the patient's unwillingness to pay for a self-pay balance? - Correct Answer -Bad debt adjustment What is the initial hospice benefit? - Correct Answer -Two 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - Correct Answer -If the patient requires ambulance transportation to a skilled nursing facility How should a provider resolve a late-charge credit posted after an account is billed? - Correct Answer -Post a late-charge adjustment to the account an increase in the dollars aged greater than 90 days from date of service indicate what about accounts - Correct Answer -They are not being processed in a timely manner What is an advantage of a preregistration program? - Correct Answer -It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - Correct Answer -Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - Correct Answer -Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts What statement applies to the scheduled outpatient? - Correct Answer -The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - Correct Answer - Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount What type of patient status is used to evaluate the patient's need for inpatient care? - Correct Answer -Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - Correct Answer -Medically necessary inpatient hospital services for at least 3 consecutive days before the skilled nursing care admission When is the word "SAME" entered on the CMS 1500 billing form in Field 0$? - Correct Answer -When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - Correct Answer -Unscheduled patients What type of provider bills third-party payers using CMS 1500 form - Correct Answer -Hospital-based mammography centers How are disputes with nongovernmental payers resolved? - Correct Answer - Appeal conditions specified in the individual payer's contract The important message from Medicare provides beneficiaries with information concerning what? - Correct Answer -Right to appeal a discharge decision if the patient disagrees with the services Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - Correct Answer -To improve access to quality healthcare If a patient remains an inpatient of an SNF (skilled nursing facility for more than 30 days, what is the SNF permitted to do? - Correct Answer -Submit interim bills to the Medicare program. 90. MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - Correct Answer -120 days passes, but the claim then be withdrawn from the liability carrier What data are required to establish a new MPI entry? - Correct Answer -The patient's full legal name, date of birth, and sex What should the provider do if both of the patient's insurance plans pay as primary? - Correct Answer -Determine the correct payer and notify the incorrect payer of the processing error What do EMTALA regulations require on-call physicians to do? - Correct Answer -Personally appear in the emergency department and attend to the patient within a reasonable time At the end of each shift, what must happen to cash, checks, and credit card transaction documents? - Correct Answer -They must be balanced What will cause a CMS 1500 claim to be rejected? - Correct Answer -The provider is billing with a future date of service Under Medicare regulations, which of the following is not included on a valid physician's order for services? - Correct Answer -The cost of the test how are HCPCS codes and the appropriate modifiers used? - Correct Answer -To report the level 1, 2, or 3 code that correctly describes the service provided If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - Correct Answer -Diagnostic and clinically- related non-diagnostic charges provided on the Tuesday, Wednesday, Thursday, and Friday before admission What is a benefit of pre-registering patient's for service? - Correct Answer - Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - Correct Answer -Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - Correct Answer -That the patient's spouse's employer must have less than 20 employees in the group health plan what organization originated the concept of insuring prepaid health care services? - Correct Answer -Blue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? - Correct Answer -It is acceptable to complete the screening form after the patient has completed the registration process and been sent to the service department If the patient cannot agree to payment arrangements, what is the next option? - Correct Answer -Warn the patient that unpaid accounts are placed with collection agencies for further processing In services lines such as cardiology or orthopedics, what does the case-rate payment methodology allow providers to do? - Correct Answer -Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? - Correct Answer -Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - Correct Answer -Code of conduct How does utilization review staff use correct insurance information? - Correct Answer -To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - Correct Answer -As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - Correct Answer -The services will be documented in the wrong record When a patient reports directly to a clinical department for service, what will the clinical department staff do? - Correct Answer -Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - Correct Answer -Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail How are patient reminder calls used? - Correct Answer -To make sure the patient follows the prep instructions and arrives at the scheduled time for service If a patient declares a straight bankruptcy, what must the provider do? - Correct Answer -Write off the account to the contractual adjustment account According to the Department of Health and Human Services guidelines, what is NOT considered income? - Correct Answer -Sale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - Correct Answer -A condition code What option is an alternative to valid long-term payment plans? - Correct Answer -Bank loans What is an effective tool to help staff collect payments at the time of service? - Correct Answer -Develop scripts for the process of requesting payments What is a benefit of electronic claims processing? - Correct Answer - Providers can electronically view patient's eligibility What does Medicare Part D provide coverage for? - Correct Answer - Prescription drugs What are some core elements of a board-approved financial policy - Correct Answer -Charity care, payment methods, and installment payment guidelines What circumstance would result in an incorrect nightly room charge? - Correct 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? - Correct Answer -Does not include required modifiers Access - Correct Answer -An individual's ability to obtain medical services on a timely and financially acceptable level Administrative Services Only (ASO) - Correct Answer -Usually contracted administrative services to a self-insured health plan Case management - Correct 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 - Correct Answer -A demand by an insured person for the benefits provided by the group contract Coordination of benefits (COB) - Correct 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 - Correct Answer -A reimbursement methodology whereby a provider agrees to provide service on a fee for service basis, but the fees are discounted by certain packages Eligibility - Correct Answer -Patient status regarding coverage for healthcare insurance benefits First dollar coverage - Correct Answer -A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses Gatekeeping - Correct Answer -A concept wherein the primary care physician provides all primary patient care and coordinates all diagnostic testing and specialty referrals required for a patient's medical care Health plan - Correct Answer -an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - Correct Answer -negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary - Correct Answer -Healthcare services that are required to preserve or maintain a person's health status in accordance with medical practice standards Out-of-area benefits - Correct Answer -healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out-of-pocket payments - Correct Answer -Cash payments made by the insured for services not covered by the health insurance plan Pre-admission review - Correct Answer -the practice of reviewing requests for inpatient admission before the patient is admitted to ensure that the admission is medically necesary Pre-existing condition limitation - Correct Answer -A restriction on payments for charges directly resulting from a pre-existing health conditions Same-day admission - Correct Answer -A cost containment practice that reduces a surgical patient's inpatient stay by requiring that pre-procedure testing and preparation are completed on an outpatient basis and the patient is admitted the same day as the procedure Self-insured - Correct Answer -Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Subrogation - Correct Answer -Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses Subscriber - Correct Answer -An employer, a union, or an association that contracts with an insurance company for the healthcare plan it offers to eligible employees Sub-specialist - Correct Answer -A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery Third-part administrator (TPA) - Correct Answer -Provides services to employers or insurance companies for utilization review, claims payment and benefit design Third-party reimbursement - Correct Answer -A general term used for the healthcare benefit payments - used to identify that for benefit plans there are three parties in the transaction Usual, customary, and reasonable (UCR) - Correct Answer -Health insurance plan reimbursement methodology that limits payment to the lower billed charges, the provider's customary charge, or the prevailing charge for the service in the community Utilization review - Correct Answer -Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients a) The impact of customer service or patient relations b) The impact of loss of direct control of accounts receivable services c) Increased costs due to vendor ineffectiveness d) Reduced internal staffing costs and a reliance on outsourced staff - Correct Answer -D The Medicare fee-for service appeal process for both beneficiaries and providers includes all of the following levels EXCEPT: a) Medical necessity review by an independent physician's panel b) Judicial review by a federal district court c) Redetermination by the company that handles claims for Medicare d) Review by the Medicare Appeals Council (Appeals Council) - Correct Answer -B Business ethics, or organizational ethics represent: a) The principles and standards by which organizations operate b) Regulations that must be followed by law c) Definitions of appropriate customer service d) The code of acceptable conduct - Correct Answer -A A portion of the accounts receivable inventory which has NOT qualified for billing includes: a) Charitable pledges b) Accounts created during pre-registration but not activated c) Accounts coded but held within the suspense period d) Accounts assigned to a pre-collection agency - Correct Answer -A Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) are Medicare established guideline(s) used to determine: a) Medicare and Medicaid provider eligibility b) Medicare outpatient reimbursement rates c) Which diagnoses, signs, or symptoms are reimbursable d) What Medicare reimburses and what should be referred to Medicaid - Correct Answer -C Days in A/R is calculated based on the value of: a) The total accounts receivable on a specific date b) Total anticipated revenue minus expenses c) The time it takes to collect anticipated revenue d) Total cash received to date - Correct Answer -C Patients are contacting hospitals to proactively inquire about costs and fees prior to agreeing to service. The problem for hospitals in providing such information is: a) That hospitals don't want to establish a price without knowing if the patient has insurance and how much reimbursement can be 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 - Correct 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 - Correct 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 - Correct 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 - Correct Answer -B Pricing transparency is defined as readily available information on the price of What is required for the UB-04/837-I, used by Rural Health Clinics to generate payment from Medicare? a) Revenue codes b) Correct Part A and B procedural codes c) The CMS 1500 Part B attachment d) Medical necessity documentation - Correct Answer -A Before classifying and subsequently writing off an account to financial assistance or bad debt, the hospital must establish policy, define appropriate criteria, implement procedures for identifying and processing accounts: a) Monitor compliance b) Have the account triaged for any partial payment possibilities c) Assist in arranging for a commercial bank loan d) Obtain the patients income tax statements from the prior 2 years - Correct Answer -A For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions: a) Are optional b) Should take place between the patient or guarantor and properly trained provider representatives c) May take place between the patient and discharge planning d) Are focused on verifying required third-party payer information - Correct Answer -B The purpose of a financial report is to: a) Provide a public record, if reqluested b) Present financial information to decision makers c) Prepare tax documents d) Monitor expenses - Correct Answer -B Which statement is an EMTALA (Emergency Medical Treatment and Active Labor Act) violation? a) Registration staff may routinely contact managed are plans for prior authorizations before the patient is seen by the on-duty physician b) Initial registration activities may occur so long as these activities do not delay treatment or suggest that treatment with not be provided to uninsured individuals c) Co-payments may be collected at the time of service once the medical screening and stabilization activities are completed d) Signage must be posted where it can be easily seen and read by patients - Correct Answer -A A claim is denied for the following reasons, EXCEPT: a) The health plan cannot identify the subscriber b) The frequency of service was outside the coverage timeline c) The submitted claim does not have the physicians signature d) The subscriber was not enrolled at the time of service - Correct Answer -C Any provider that has filed a timely cost report may appeal an adverse final decision received from the Medicare Administrative Contractor (MAC). This appeal may be filed with a) A court appointed federal mediator b) The Department of Health and Human Services Provider Relations Division c) The Office of the Inspector General d) The Provider Reimbursement Review Board - Correct Answer -D Charges, as the most appropriate measurement of utilization, enables a) Generation of timely and accurate billing b) Managing of expense budgets c) Accuracy of expense and cost capture d) Effective HIM planning - Correct Answer -???Number 24??? Ambulance services are billed directly to the health plan for a) All pre-admission emergency transports b) Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility c) The portion of the bill outside of the patient's self-pay d) Transports deemed medically necessary by the attending paramedic-ambulance crew - Correct Answer -C An individual enrolled in Medicare who is dissatisfied with the government's claim determination is entitled to reconsideration of the decision. This type of appeal is known as a) A beneficiary appeal b) A Medicare supplemental review c) A payment review d) A Medicare determination appeal - Correct Answer -A facility-free" for 60 consecutive days c) Each calendar year d) Up to 60 days - Correct 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 - Correct 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 - Correct 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 - Correct Answer -D Once the price is estimated in the pre-service stage, a provider's financial best practice is to a) Explain to the patient their financial responsibility and to determine the plan for payment b) Allow the patient time to compare prices with other providers c) Lock-in the prices d) Have another employee double check the price estimate - Correct Answer -A 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 - Correct Answer -B All of the following are conditions that disqualify a procedure or service from being paid for by Medicare EXCEPT a) Medically unnecessary b) Not delivered in a Medicare licensed care setting c) Offered in an outpatient setting d) Services and procedures that are custodial in nature - Correct Answer -D All of the following are forms of hospital payment contracting EXCEPT a) Contracted Rebating b) Per Diem Payment c) Fixed Contracting d) Bundled Payment - Correct Answer -A 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 - Correct Answer -D With the advent of the Affordable Care Act Health Insurance Marketplaces and the expansion of Medicaid in some states, it is more important than ever for hospitals to a) Reschedule the visit for non-payment of a prior balance b) Strictly limit charity care and bad-debt c) Collect patient's self-pay and deductibles in the first encounter d) Assist patients in understanding their insurance coverage and their financial obligation - Correct Answer -D A nightly room charge will be incorrect if the patient's a) Discharge for the next day has not been charted a) Ability to pursue extraordinary collection activities b) Early and productive communication with a third-party payer c) Accurate billing d) That access staff will have the compete and valid information needed to finalize any remaining pre-access activities - Correct Answer -C Once the EMTALA requirements are satisfied a) Third-party payer information should be collected from the patient and the payer should be notified of the ED visit b) The patient then assumes full liability for services unless a third- party is notified or the patient applies for financial assistance with the first 48 hours c) The remaining registration processing is initiated at the bedside or in a registration area d) An initial registration records is completed so that the proper coding can be initiated - Correct Answer -C This directive was developed to promote and ensure healthcare quality and value and also to protect consumers and workers in the healthcare system. This directive is called a) Payer quality monitoring b) Medicare patient and staff safety standards c) Joint Commission for Accreditation of Healthcare Organizations (JCAHO) safety d) Patient bill of rights - Correct Answer -D A scheduled inpatient represents an opportunity for the provider to do which of the following? a) Refer the patient to another location with the health system b) Comply with EMTALA (Emergency Medical Treatment and Labor Act) requirements before service c) Complete registration and insurance approval before service d) Register the patient after he or she is placed in a bed on that service unit. - Correct Answer -C The first and most critical step in registering a patient, whether scheduled or unscheduled, is a) Having the patient initial the HIPAA privacy statement b) Verifying insurance to activate the patient medical record c) Verifying the patient's identification d) Check the schedule for treatment availability - Correct Answer -C The legal authority to request and analyze provider clam documentation to ensure that IPPS services were reasonable and necessary is given to a) Recovery Audit Contractors (RAC) b) The Office of the U.S. Inspector General (OIG) c) All health plans d) State insurance commissioners - Correct Answer -B An advantage of a pre-registration program is a) The opportunity to reduce processing times at the time of service b) The ability to eliminate no-show appointments c) The opportunity to reduce the corporate compliance failures within the registration process d) The marketing value of such a program - Correct Answer -C Claims with dates of service received later than one calendar year beyond the date of service, will be a) Denied by Medicare b) The provider's responsibility but can be deemed charity care c) Fully paid with interest d) The full responsibility of the patient. - Correct 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 - Correct 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 - Correct 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 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 - Correct 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 - Correct Answer -D The ICD-10 codes set and CPT/HCPCS code sets combines provide a) Pricing floors for services b) The financial data required for activity-based costing c) Patients an overview of services covered by their health insurance plan d) The specificity and coding needed to support reimbursement claims - Correct Answer -D A recurring/series registration is characterized by a) A creation of multiple registrations for multiple services b) The creation of one registration record for multiple days of service c) The creation of multiple patient types for one date of service d) The creation of one registration record per diagnosis per visit - Correct Answer -B Under EMTALA (Emergency Medical Treatment and Labor Act) regulations, the provider may not ask about a patient's insurance information if it would delay what? a) Complete course of treatment b) Medical screening and stabilizing treatment c) Admission to observation status d) Transfer to another facility - Correct Answer -B In resolving medical accounts, a law firm may be used as: a) An independent auditor of a financial assistance policy b) Legal counsel to patients regarding financing options c) An independent broker of patient financial assistance from banks d) A substitute for a collection agency - Correct Answer -D The unscheduled "direct" admission represents a patient who: a) Is admitted from a physician's office on an urgent basis b) Arrives at the hospital via ambulance for treatment in the emergency room c) Is an ambulatory patient who collapses in the hospital lobby d) Arrives on the medical helicopter for trauma services - Correct Answer -A In the balance resolution process, providers should: a) Stress to the patient that serious consequences may result from refusal to pay b) Remind the patient of their legal responsibility to pay the balance due c) Ask the patient if he or she would like to receive information about payment options and supportive financial assistance programs d) Tag the patients record for possible financial assistance for bad debt - Correct Answer -C Which of the following in NOT included in the Standardized Quality Measures a) Clinical outcomes b) Patient perceptions c) Health care processes d) Cost of services - Correct Answer -D In the pre-service stage, the requested service is screened for medical necessity, health plan coverage and benefits are verified and: a) Billing authorization is signed by the patient b) The patient signs the consents for treatment c) The patient signs a statement attesting an understanding and acceptance of payment policies d) Pre-authorization are obtained - Correct Answer -D Improving the overall patient experience requires revenue cycle leadership and staff to simultaneously be: a) Clear on policies and consistent in applying the policies b) Careful in screening patient demands c) Monitoring the costs and charges the patient incurs d) Inquisitive, responsive and flexible - Correct Answer -A Hospitals need which of the following information sets to assess a patient's financial status: a) Income, expenses, debt b) Patient and guarantor's income, expenses and assets c) Income, expenses and capacity to take on more debt d) Assets liquidity, Income, expenses, credit worthiness - Correct Answer -B For scheduled patients, important revenue cycle activities I the Time of Service stage DO NOT INCLUDE: d) The Internal Revenue Service - Correct 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 - Correct 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 c) Sold to a collection agency d) Treated as the cost of doing business - Correct Answer -B When there is a request for service the scheduling staff member must confirm the patient's unique identification information to: a) Verify the patient's insurance coverage if the patient is a returning customer b) Ensure that she/he accesses the correct information in the historical database c) Confirm that physician orders have been received d) Check if any patient balance due - Correct Answer -B Identifying the patient, in the MPI, creating the registration record, completing medical necessity screening, determining insurance eligibility and benefits resolving managed care, requirements and completing financial education/resolution are all a) The data collection steps for scheduling and pre-registering a patient b) Registration steps that must be completed before any medical services are provided c) The steps mandated for billing Medicare Part A d) The process of closing an account - Correct Answer -A Insurance verification results in which of the following a) The accurate identification of the patient's eligibility and benefits b) The consistent formatting of the patient's name and identification number The resolution of managed care and billing requirements The identification of physician fee schedule amounts and the NPI (national provider identifier) numbers - Correct Answer -A A four digit number code established by the National Uniform Billing Committee (NUBC) that categorizes/classifies a line item in the charge master is known as a) HCPCs codes b) ICD-10 Procedural codes c) CPT codes d) Revenue codes - Correct Answer -D The importance of Medical records being maintained by HIM is that the patient records: a) Are evidence used in assessing the quality of care b) Are the primary source for clinical data required for reimbursement by health plans and liability payers C) Are the strongest evidence and defense in the event of a Medicare Audit d) Are the evidence cited in quality review - Correct Answer -B Medicare patients are NOT required to produce a physician order to receive which of these services a) Diagnostic Mammography, flu vaccine, or B-12 shots b) Diagnostic Mammography, flu vaccine, or pneumonia vaccine c) Screening Mammography, flu vaccine or pneumonia vaccine d) Screening Mammography, flu vaccine or B-12 shots - Correct 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 - Correct 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 - Correct Answer - C In Chapter 7 straight bankruptcy filling a) The court establishes a creditor payment schedule with the longest outstanding claims paid first The HCAHPS (hospital consumer assessment of healthcare providers and systems) initiative was launched to a) Gather national date on overall trust in the nation's health care system b) Create a national database on physician quality c) Provide a standardized method for evaluating patient's perspective on hospital care. ? d) Provide data for building shared savings reimbursement for quality procedures. - Correct Answer -C Health Plan Contracting Departments do all of the following EXCEPT a) Establish a global reimbursement rate to use with all third-party payer b) Review all managed care contracts for accuracy for loading contract terms into the patient accounting system c) Review payment schemes to ensure that the health plan and provider understand how reimbursements must be calculated d) Review contracts to ensure the appeals process for denied claims is clearly specified - Correct Answer -A The benefit of Medicare Advantage Plan is a) It is a less costly plan compared to traditional Medicare b) Patients may retain a primary care physician and see another physician for a second opinion at no charge c) Patients generally have their Medicare-coverage healthcare through the plan and do not need to worry about "part a" or "part b" benefits d) Patients receive significant discounting on services contracted by the federal government - Correct Answer -C Once the EMTALA requirements are satisfied a) Third-party payer info should be collected from the pt and the payer should be notified of the ED visit b) An initial registration record is completed so that the proper coding can be initiated c) The pt then assumes full liability for services unless a third-party payer is notified or the pt applies for financial assistance within the first 48 hours d) The remaining registration processing is initiated either at the bedside or In a registration area - Correct Answer -A The soft cost of a dissatisfied customer is a) The "cost" of staff providing extra attention in trying to perform service recovery b) The customer passing on info about their negative experience to potential pts or through social media channels c) Potentially negative treatment outcomes leading to expanding length-of- stay d) Lowered quality outcomes for the dissatisfied pt - Correct Answer -B Concurrent review and discharge planning a) Occurs during service b) Is performed by the health plan during the time of service c) Is a significant part of quality and is performed by the clinical treatment team d) Is performed at discharge with the pt - Correct Answer -A In a self-insured (or self-funded) plan, the costs of medical care are a) Borne by the employer on a pay-as-you-go basis b) Backed-up by stop-loss insurance against a catastrophic claim c) Mandated by the Affordable Care Act for small businesses unable to obtain commercial coverage d) Created by a combination of employer and employee contributions - Correct Answer -A In choosing a setting for pt financial discussions, organizations should first and foremost a) Have processes in place to document the discussions b) Assess locations for convenience, professionalism, and comfort c) Respect the pts privacy d) Ensure all staff involved are properly trained and the pt financial education is included in all discussions - Correct Answer -C All of the following are steps in safeguarding collections EXCEPT a) Placing collections in a lock-box for posting review the next business day b) Posting the payment to the pts account c) Completing balance activities d) Issuing receipts - Correct Answer -D Which option is a government-sponsored health care program that is financed through taxesand general revenue funds a) Medicaid b) Medicare c) Insurance exchange d) Social security - Correct Answer -B It is important to calculate reserves to ensure a) Stable financial operations and accurate financial reporting b) Collateral for credit c) Expense coverage in the event of a revenue short fall 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 - Correct 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 - Correct 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 - Correct 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 - Correct 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 - Correct 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 d) Conduct an audit of all the effected providers claims within the past twelve months - Correct Answer -C A recurring/series registration is characterized by a) The creation of one registration record for multiple days of service b) The creation of multiple registrations for multiple services c) The creation of one registration record per diagnosis per visits d) The creation of multiple pt types for one date of service - Correct Answer -A It is important to have high registration quality standards because a) Inaccurate or incomplete pt data will delay payment or cause denials b) Incomplete registrations will trigger exclusion from Medicare participation c) Inaccurate registration may cause discharge before full treatment is obtained d) Incomplete registrations will raise satisfaction scores for the hospital - Correct Answer -A When recovery audit contractors (RAC) identify improper payments as over payments the claims processing contractor must a) Assume legal responsibility for repaying the overage amount b) Make recovery of the overpayment the top processing priority c) Send a demand letter to the provider to recover the over payment amount d) Conduct an audit of all the effected providers claims within the past 12 months - Correct Answer -C Internal controls addressing coding and reimbursement changes are put I place to guard against a) Underpayments b) Denials c) Compliance fraud by upcoding d) Charge master error - Correct Answer -C The pt discharge process begins when a) The physician writes the discharge orders b) Clinical services are completed and pt accounts have all the info necessary to bill c) The physician writes the discharge orders and the third-party payer sign- off on the necessity of the services provided d) Clinical services are completed, pt accounts can generated and accurate bill and there is agreement o the handling of pt financial responsibilities - Correct Answer -A c) Support that choice, providing that the discussion does not interfere with pt care or disrupt pt flow d) Decline such request as finance discussions can disrupt pt care and pt flow - Correct Answer -C The office of inspector general (OIG) publishes a compliance work plan a) Monthly b) Quarterly c) Semi-annually d) Annually - Correct Answer -D What are collection agency fees based on? - Correct Answer -A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - Correct Answer -Birthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - Correct Answer - Case rates What customer service improvements might improve the patient accounts department? - Correct Answer -Holding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - Correct Answer -Inform a Medicare beneficiary that Medicare may not pay for the order or service What type of account adjustment results from the patient's unwillingness to pay for a self-pay balance? - Correct Answer -Bad debt adjustment What is the initial hospice benefit? - Correct Answer -Two 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - Correct Answer -If the patient requires ambulance transportation to a skilled nursing facility How should a provider resolve a late-charge credit posted after an account is billed? - Correct Answer -Post a late-charge adjustment to the account an increase in the dollars aged greater than 90 days from date of service indicate what about accounts - Correct Answer -They are not being processed in a timely manner What is an advantage of a preregistration program? - Correct Answer -It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - Correct Answer -Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - Correct Answer -Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts What statement applies to the scheduled outpatient? - Correct Answer -The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - Correct Answer - Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount What type of patient status is used to evaluate the patient's need for inpatient care? - Correct Answer -Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - Correct Answer -Medically necessary inpatient hospital services for at least 3 consecutive days before the skilled nursing care admission When is the word "SAME" entered on the CMS 1500 billing form in Field 0$? - Correct Answer -When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - Correct Answer -Unscheduled patients If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - Correct Answer - Neither enrolled not entitled to benefits Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what? - Correct Answer -Disclosure rules for consumer credit sales and consumer loans What is a principal diagnosis? - Correct Answer -Primary reason for the patient's admission Collecting patient liability dollars after service leads to what? - Correct Answer -Lower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - Correct Answer -50% of the current deductible amount What service provided to a Medicare beneficiary in a rural health clinic (RHC) is not billable as an RHC services? - Correct Answer -Inpatient care What code indicates the disposition of the patient at the conclusion of service? - Correct Answer -Patient discharge status code What are hospitals required to do for Medicare credit balance accounts? - Correct 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? - Correct 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: - Correct Answer -A valid CPT or HCPCS code What will cause a CMS 1500 claim to be rejected? - Correct Answer -The provider is billing with a future date of service Under Medicare regulations, which of the following is not included on a valid physician's order for services? - Correct Answer -The cost of the test how are HCPCS codes and the appropriate modifiers used? - Correct Answer -To report the level 1, 2, or 3 code that correctly describes the service provided If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - Correct Answer -Diagnostic and clinically- related non-diagnostic charges provided on the Tuesday, Wednesday, Thursday, and Friday before admission What is a benefit of pre-registering patient's for service? - Correct Answer - Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - Correct Answer -Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - Correct Answer -That the patient's spouse's employer must have less than 20 employees in the group health plan what organization originated the concept of insuring prepaid health care services? - Correct Answer -Blue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? - Correct Answer -It is acceptable to complete the screening form after the patient has completed the registration process and been sent to the service department If the patient cannot agree to payment arrangements, what is the next option? - Correct Answer -Warn the patient that unpaid accounts are placed with collection agencies for further processing In services lines such as cardiology or orthopedics, what does the case-rate payment methodology allow providers to do? - Correct Answer -Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? - Correct Answer -Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - Correct Answer -Code of conduct How does utilization review staff use correct insurance information? - Correct Answer -To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - Correct Answer -As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - Correct Answer -The services will be documented in the wrong record When a patient reports directly to a clinical department for service, what will the clinical department staff do? - Correct Answer -Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - Correct Answer -Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail How are patient reminder calls used? - Correct Answer -To make sure the patient follows the prep instructions and arrives at the scheduled time for service If a patient declares a straight bankruptcy, what must the provider do? - Correct Answer -Write off the account to the contractual adjustment account According to the Department of Health and Human Services guidelines, what is NOT considered income? - Correct Answer -Sale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - Correct Answer -A condition code What option is an alternative to valid long-term payment plans? - Correct Answer -Bank loans What is an advantage of using a collection agency to collect delinquent patient accounts? - Correct Answer -Collection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? - Correct Answer - revenue codes identify the payer When a patient's illness results in an unusually high amount of medical bills not covered by insurance or other patient pay resources, what type of account is created - Correct Answer -catastrophic charity What happens when a patient receives non-emergent services from and out- of-network provider? - Correct Answer -Patient payment responsibility is higher Every patient who is new to the healthcare provider must be offered what? - Correct Answer -A printed copy of the provider's privacy notice How may a collection agency demonstrate its performance? - Correct Answer -Calculate the rate of recovery What is true of the information the provider supplies to indicate that an authorization for service has been received from the patient's primary payer? - Correct Answer -It is posted on the remittance advice by the payer What standard claim forms are currently used by the healthcare industry to submit claims to third-party payers? - Correct Answer -The UB-04 and the CMS 1500 Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information? - Correct Answer -Obtain the required demographic and insurance information before services are rendered Coordination of benefits (COB) - Correct 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 - Correct Answer -A reimbursement methodology whereby a provider agrees to provide service on a fee for service basis, but the fees are discounted by certain packages Eligibility - Correct Answer -Patient status regarding coverage for healthcare insurance benefits First dollar coverage - Correct Answer -A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses Gatekeeping - Correct Answer -A concept wherein the primary care physician provides all primary patient care and coordinates all diagnostic testing and specialty referrals required for a patient's medical care Health plan - Correct Answer -an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - Correct Answer -negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary - Correct Answer -Healthcare services that are required to preserve or maintain a person's health status in accordance with medical practice standards Out-of-area benefits - Correct Answer -healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out-of-pocket payments - Correct Answer -Cash payments made by the insured for services not covered by the health insurance plan Pre-admission review - Correct Answer -the practice of reviewing requests for inpatient admission before the patient is admitted to ensure that the admission is medically necesary Pre-existing condition limitation - Correct Answer -A restriction on payments for charges directly resulting from a pre-existing health conditions Same-day admission - Correct Answer -A cost containment practice that reduces a surgical patient's inpatient stay by requiring that pre-procedure testing and preparation are completed on an outpatient basis and the patient is admitted the same day as the procedure Self-insured - Correct Answer -Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Subrogation - Correct Answer -Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses Subscriber - Correct Answer -An employer, a union, or an association that contracts with an insurance company for the healthcare plan it offers to eligible employees Sub-specialist - Correct Answer -A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery Third-part administrator (TPA) - Correct Answer -Provides services to employers or insurance companies for utilization review, claims payment and benefit design Third-party reimbursement - Correct Answer -A general term used for the healthcare benefit payments - used to identify that for benefit plans there are three parties in the transaction Usual, customary, and reasonable (UCR) - Correct Answer -Health insurance plan reimbursement methodology that limits payment to the lower billed charges, the provider's customary charge, or the prevailing charge for the service in the community Utilization review - Correct Answer -Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Charge - Correct Answer -The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Cost - Correct Answer -The definition of cost varies by party incurring the expense Price - Correct Answer -the total amount a provider expects to be paid by payers and patients for healthcare services Care purchaser - Correct Answer -Individual or entity that contributes to the purchase of healthcare services Payer - Correct Answer -An organization that negotiates or sets rates for provider services, collects revenue through premium payments or tax dollars, processes provider claims for service, and pays provider claims using collected premium or tax revenues Provider - Correct Answer -An entity, organization, or individual that furnishes a healthcare service Out of pocket payment - Correct Answer -The portion of the total payment for medical services and treatment for which the patient is responsible, including copayments, coinsurance, and deductibles Price transparency - Correct Answer -In health care, readily available information on the price of healthcare services that, together, with other information helps define the value of those services and enables patients and other care purchasers to identify, compare, and choose providers that offer the desired level of value What is the intended outcome of collaborations made through an ACO delivery system for a population of patients? - Correct Answer -To eliminate duplicate services, prevent medical errors and ensure appropriateness of care. Historically, revenue cycle has delt with contractual adjustments, bad debt and charity deductions from gross revenue. Although deductions continue to exist, the definition of net revenue has been modified through the implementation of ASC 606. Developed by the Financial Accounting Standards Board (FASB), this change became effective in 2018. What is the new terminology now employed in the calculation of net patient services revenues? - Correct Answer -Explicit prices concessions and implicit price concessions Key performance indicators set standards for A/R and provide a method for measuring the control and collection of A/R. What are the two KPIs used to monitor performance related to the production and submission of claims to third party payers and patients (self-pay)? - Correct Answer -Elapsed days from discharge to final bill and elapsed days from final bill to claim/bill submission. Consents are signed as part of the post-services process. - Correct Answer - True **False Patient service costs are calculated in the pre-service process for schedule patients - Correct Answer -**True False The patient is scheduled and registered for service is a time-of-service activity - Correct Answer -True **False The patient account is monitored for payment is a time-of-service activity - Correct Answer -True **False Case management and discharge planning services are a post-service activty - Correct Answer -True **False Sending the bill electronically to the health plan is a time-of-service activity - Correct Answer -True **False What happens during the post-service stage? - Correct Answer -**A. Final coding of all services, preparation and submission of claims, payment processing and balance billing and resolution. B. Orders are entered, results are reported, charges are generated, and diagnostic and procedural coding is initiated. C. The encounter record is generated, and the patient and guarantor information is obtained and/or updated as required. D. The focus is on the patient and his/her financial care, in addition to the clinical care provided for the patient. The following statements describe best practices established by the Medical Debt Task Force. Check the box next to the True statements - Correct Answer -**Educate Patients **Coordinate to avoid duplicate patient contacts Exercise moderate judgement when communicating with providers about scheduled services **Be consistent in key aspects of account resolution Report to healthcare plans when the patient's account is transferred to collection agency **Follow best practices for communication Which option is NOT a main HFMA Healthcare Dollars & Sense® revenue cycle initiative? - Correct Answer -A. Patient Financial Communications B. Price Transparency C. Medical Account Resolution **D. Process Compliance What is the objective of the HCAHPS initiative? - Correct Answer -**A. To provide a standardized method for evaluating patients' perspective on hospital care. B. To provide clear communication and good customer service, which will give the provider a competitive edge. C. To conduct evaluations concerning patients' perspective on hospital care. D. To make certain that during registration key information is verified by means of a picture ID and an insurance card. Which option is NOT a department that supports and collaborates with the revenue cycle? - Correct Answer -A. Information Technology B. Clinical Services C. Finance **D. Assisted Living Services Which option is NOT a continuum of care provider? - Correct Answer -A. Physician **B. Health Plan Contracting C. Hospice D. Skilled Nursing Facility C. To reform the healthcare system into a system that rewards greater value, improves the quality of care and increases efficiency in the delivery of services. D. To provide financial incentives to physicians for reporting quality data to CMS. Which of these statements describes the new methodology for the determination of net patient service revenue: - Correct Answer -A. Net patient service revenue is defined as the average payment amount for the payer but not recorded until the end of the month processing is completed. B. Gross patient service revenue is recorded as net patient service revenue until such time as all payments are received. **C. Net patient service revenue is defined as the total incurred charges, less the explicit price concession, less any applicable implicit price concession(s) as applied to the specific portfolio of accounts. D. Net patient service revenue is gross revenue minus any contractual adjustments applicable to the account. Any additional adjustments are not recorded until the account reaches a zero balance. E. Net patient service revenue is the sum of the balances of all charges and payments recorded in the accounting period. What are KPIs? - Correct Answer -A. Benchmarks which are used to compare Key Performance Indicators in an organization to an agreed upon average or expected standard within the same industry. **B. Key performance indicators, which set standards for accounts receivable (A/R) and provide a method of measuring the collection and control of A/R. C. Days in A/R is calculated based on the value of the total accounts receivable on a specific date. D. A component that can divide the accounts receivable into 30, 60, 90, 120 days, and over 120 days categories, based on the date of service/discharge While the highest level of differentiation among patients is scheduled patient vs unscheduled patient, a variety of patient types are routinely identified in both the acute and non-acute settings. Which patient types are typically considered acute care patient types? - Correct Answer - Observation, newborn, Emergency (ED) Accurate identification of the patient is the first step in the scheduling process. Identifiers used in various combination to achieve accurate patient identification include? - Correct Answer -Full legal name, date of birth, sex and social security number Pre-registration is defined as: - Correct Answer -The collection of demographic information, insurance data, financial information, providing reminders, prep information, and identifying the potential need for financial assistance for scheduled patients. Medicare has unique features not found in other health plan programs. It is government sponsored and financed through taxes and general revenue funds. Which of the following statements accurately describes the various Medicare benefits programs: - Correct Answer -Medicare Part A provides benefits for inpatient hospital services, skilled nursing care and home health care; Medicare Part B covers outpatient and professional services, Medicare Part C or Medicare Advantage plans are managed care plans combining Part A and Part B Coverages; and Medicare Part D is the prescription drug coverage benefit. Which of the following statements about Medicaid eligibility is not true? - Correct Answer -Medicaid categories are restricted to children, pregnant women and elderly in nursing homes. Examples of managed care plans include: - Correct Answer -All of the above Patient Financial Communications best practices include all of the following activities except: - Correct Answer -Collecting payment or initiating the process to immediately remove the patient from the service schedule. Which statement includes the required components of an accurate pricing determination? - Correct Answer -Insurance coverage and benefits, service or test involved, diagnosis and procedure codes, total estimated charges, adjudication calculations based on the patient's benefit package. The value of a robust scheduling and pre-registration process includes all of the following except: - Correct Answer -Identification of patients who are likely to be "no shows". Which patients are considered scheduled? - Correct Answer -A. Observation Patients B. Emergency Department Patients **C. Recurring/Series Patients D. Hospice Care Name the guideline that Medicare established to determine which diagnoses, signs, or symptoms are payable. - Correct Answer -A. Patient Identifiers **B. Local Coverage Determinations C. Advance Beneficiary Notice D. Scheduling Instructions What is the purpose of insurance verification? - Correct Answer -A. To identify information that does not have to be collected from the patient. **B. To ensure accuracy of the health plan information. C. To effectively complete the MSP screening process. D. To complete guarantor information if the guarantor is not the patient. Which option is a federally-aided, state-operated program to provide health and long-term care coverage? - Correct Answer -A. Medicare **B. Medicaid C. Self-Insured Plans D. Liability Coverage Each type of service has unique billing rules which come into play during the provision of service. For the skilled nursing facility, care is covered if which of the following factors are present: - Correct Answer -The patient required skilled services on a daily basis and those services can only be provided on an inpatient basis in a SNF. DRG's are a system of classifying inpatients on the basis of diagnoses, procedures, and co-morbidities for purposes of payment to hospitals. Each DRG includes: - Correct Answer -A relative weight which is multiplied by the established base payment rate to calculate the reimbursement for a specific DRG. For exceptionally costly cases over a set dollar amount, an outlier payment is added to the calculated payment. PPO networks represent one form of discounting commonly used by commercial payers. The silent PPO represents: - Correct Answer -A discounting scheme whereby health plans apply generic PPO rates to discount a provider's claims, even though there is no contractual arrangement between the silent PPO and the provider. The concept of timely filing of claims is important to providers, payers and patients. Thus, providers are required to comply with timely claim filing rules. Which of the following statements are NOT true about timely filing limitations: - Correct Answer -Payers will waive timely filing denials for claims filed over a year from date of service. What does EMTALA require hospitals to do? - Correct Answer -**A. To provide a medical screening examination and stabilizing treatment to every person presenting at an ED and requesting medical evaluation or treatment. B. To initially triage patients, where a "quick" registration record is generated to specifically allow order entry. C. To complete a standardized form signed by all patients that is used to inform the patient about the admission and conditions which must be agreed upon. D. To confirm information that may be used to identify the patient in the provider's MPI, which includes the patient's full, legal name, SSN, and/or date of birth. In what manner do case managers assist revenue cycle staff? - Correct Answer -A. By reviewing a patient's individual case and recommend treatment changes. B. With monitoring the progression of high resource consumptive cases. C. By estimating how long the patient will be in the hospital and what the expected outcome will be. **D. Providing assistance with written appeals to health plans related to utilization and other care issues. Why is it critical that a chargemaster is reviewed and updated regularly? - Correct Answer -**A. To ensure it supports and represents the services provided within the organization. B. To ensure the most appropriate measure of the utilization of resources. C. So the CPT databases can have the most current and accurate information. D. Because charge descriptions can vary greatly between providers. What is the responsibility of HIM? - Correct Answer -**A. To maintain all patient medical records B. To make information available instantly and securely to authorized users C. To denote the medical procedures performed by a healthcare provider on a patient D. To substantiate health insurance claims filed by the patient, the physician, and the provider What are claim edits? - Correct Answer -A. Various data sources including Medicare and Medicaid bulletins and manuals, individual health plan manuals B. A multi-stakeholder collaboration of more than 130 organizations — providers, health plans, vendors, and government agencies **C. Rules developed to verify the accuracy and completeness of claims based on each health plan's policies D. The submission, receipt, and processing of automated claims, thereby eliminating mail time and reducing data entry time Which statement is NOT a unique billing rule specific to providers? - Correct Answer -A. Overall aggregate payments made to a hospice are subject to a "cap amount", calculated by the MAC at the end of the hospice cap period. B. With the exception of physician services, Medicare reimbursement for hospice care is made at one of four pre-determined rates for each day of hospice care. C. When billing services on a UB-04/837-I, specific CPT codes are collapsed into a single revenue code (520 or 521). **D. A patient may be balance billed for whatever amount the non- contracting physician charges above the health plan's reimbursement amount. Which of the following statements does not apply to billing during the COVID-19 public health emergency: - Correct Answer -A. Hospitals may change a sub-acute unit into an acute care unit without advanced approval from CMS. **B. Telemedicine claims are not payable if the patient conducts the telemedicine visit from home. C. CMS developed the concept of hospitals without walls to increase ICU and med-surge inpatient capacity during the COVID-19 pandemic. for legal review if the outside vendor's staff represents themselves as employees of the healthcare facility. Each hospital covered by the 501(r) regulations is required to develop a financial assistance policy. Which of the following elements is NOT a required element of the policy? - Correct Answer -The notice that individuals eligible for financial assistance under this policy may be charged more that the amount generally billed (AGB) to insured patients. Place the daily reconciliation process steps in the correct sequential order: - Correct Answer -Obtain totals of all payments - cash, check, credit card, and debit card Divide remittances into batches and obtain a second total of the electronic remittance advices by payment and contractual allowances Endorse checks immediately. Prepare the bank deposit for all payments. Separate cash payments and contractual adjustments into separate batches and use separate payments and adjustment codes. Post unidentified payments to an unidentified cash account (deposit everything, do not hold unidentified payments) Balance and post batches. Balance payments to the bank deposit. Balance the bank deposit to the general ledger. Sue Smith came into the hospital. Her insurance provider sent an EFT directly into the hospital's account at the bank. John, the hospital representative, receives an electronic Level 2 ERA. What should he do next? - Correct Answer -**A. Manually match the ERA to the patient account. B. Nothing unless there is an error. What is EFT? - Correct Answer -**A. The electronic transfer of funds from payer to payee through the banking system. B. The establishment of internal audits by personnel outside the involved department. C. A standardized healthcare claim payment/advice known as the 835 format. D. A process that requires the separation of duties when processing patient payments. Which statement is false regarding credit balances? - Correct Answer -A. A small credit policy should be matched by a similar policy for small debit balances. B. Tracking reports should be developed to identify internal charge credits versus external charge credits. C. Hospital generated statements should be sent to patients regarding small credit balances. **D. There are no CMS hospital compliance requirements regarding credit balances. Which option is NOT a type of denial? - Correct Answer -A. Technical B. Clinical C. Underpayment **D. Contractual Adjustment Which option is NOT a lien type? - Correct Answer -A. Judicial **B. Subrogation C. Statutory D. Agreement (Consensus) Based on what you have just read, which activity is not considered when initiating self-pay follow-up and account resolution activities? - Correct Answer -A. Poverty Guidelines B. Financial Profile C. Presumptive Financial Assistance Determination **D. Patient Open Balance Billing Which option is NOT a required component of a FAP? - Correct Answer -A. Eligibility criteria B. Application process C. Application assistance **D. Out-of-network providers Which option is NOT a bankruptcy type governed by the 1979 Bankruptcy Act? - Correct Answer -A. Straight bankruptcy B. Debtor reorganization **C. Creditor priority D. Debtor rehabilitation Which evaluation criteria demonstrates reputation expectations: - Correct Answer -A. The agency's Yelp score and consumer comments. B. The amount of monies collected monthly. **C. The employment of staff who have documented experience working in financial areas of health care. D. The high turnover rate for entry level employees. Agency fees are: - Correct Answer -A. Paid by patients. **B. The cost to the provider for collection agency monies offset by the return on baddebt accounts. C. Only reported annually to the provider. D. Waived for accounts aged greater than one year from date of service. The correct way to handle the retention and payment of agency fees is: - Correct Answer -A. The agency provides an annual settlement of monies received by the health care provider and the agency. B. Compare estimated collection costs to actual costs incurred. C. Validate bank deposits weekly as funds are received from the agency.