Healthcare Revenue Cycle Management, Exams of Nursing

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CRCR STUDY| 103 QUESTIONS| Correct

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code of conduct - ANSWERShospital establish compliance standards Purpose of OIG work plan? - ANSWERScommunicate issues that will be reviewed during the year for compliance with Medicare regulations Medicare pt. admitted on Friday, what services fall within the three day window rule? - ANSWERSDx services and related charges provided on the W,R, and F before adm. What does modifier allow a provider to do? - ANSWERSReport a specific circumstance that affected a procedure or service without changing the code or its definition Out pt. dx services provided within 3 days of adm. of a medicare benef. to an IPPS hospt, what must happen to these charges - ANSWERScombined with the in pt. bill and paid under the MS-DRG system Why is OIG pursuing the medicare Secondary Payer - ANSWERSreviews medicare payments for beneficiaries who have other insurance and assesses the effect. of procedures in preventing inappro. medcare payments for benef. with other ins. coverage Recurring or series registration? - ANSWERSone reg. record is created for multi days of service Nonemergency pt. who comes for service w/out prior notif. to the provider called? - ANSWERSunscheduled pt. stmnts apply to observ. pt. type - ANSWERSused to evaluate the need for an in pt. adm. which services are hospice programs required to provide on an around the clock basis - ANSWERSphysician, nursing, pharmacy purpose of initial step in put pt. testing scheduling process - ANSWERSidentifying the correct pt. in the providers database or add the pt. to the database scheduler instructions are used to prompt the scheduler to do what? - ANSWERScomplete the scheduling process correctly based on service requested

medicare guidelines require that when a test is ordered for which an LCD or NCD exists, the info provided on the order must include which of the following? - ANSWERSdocumentation of the medical necessity for the test advantage of pre reg. program? - ANSWERSreduces processing times at the time of serivce what data are required to est. a new MPI entry? - ANSWERSpts. name, DOB, sex Which HIPAA trans. set provides electronic processing of ins, verif requests and responses? - ANSWERSthe 270-271 set a mother and father both cover their 16 yo child as a dep. on their health ins, plans, which both follow the bday rule. mothers dob is 1-19-68 and fathers dob is 7-19-67; whose plan is primary - ANSWERSmothers true about third party payers? - ANSWERSpayments received by the provider from the payer respon. for reimbursing the provider for the pts. covered services co-payment? - ANSWERSfixed amt. that is due for a specific service pts annual out of pocket limitation is 3000, excluding deduct. to date this cal. year the pt has satisfied the 500 deduct. and has paid 2300 in co insurance to various providers. max amount of coinsurance the pt will owe - ANSWERS type of plan that allows the subscriber to pay lower premium costs in return for a higher deductible? - ANSWERSconsumer directed health plan characteristic of a managed care contracted methodology - ANSWERSprospectively set rates for in pt. and out pt. services which provision protects the pt. from medical expenses that exceed a pre set level - ANSWERSstop loss what document must a primary care phys. send to an HMO pt. to authorize a visit to a specialist for add. testing or care? - ANSWERSreferral activities are completed when a scheduled, pre reg pt. arrives for service? - ANSWERSactivating the record, obtaining signatures, and finalizing financial issues under EMTALA reg., the provider may not ask about a pts. ins. info if it would delay what - ANSWERSmedical screening and stabilizing treatment collecting pt liability dollars after service leads to what - ANSWERSincreased efforts by pt acct staff to resolve these balanaces

important message from medicare provides beneficiaries with info concerning what? - ANSWERSright to appeal a discharge decision if the pt disagrees with the plan which of the following is a step in the discharge process? - ANSWERShave case management services complete the discharge plan what curcumstances would result in an incorrect nightly room charge? - ANSWERSif pt. transfer from the ICU to medical/surgical floor is not reflected in the reg system which stmnt describes the goal of fin counseling services - ANSWERShelp the pt. understand insurance coverage, including what the pt will owe for the current services hospital has an APC based contract for the payment of out pt. services. total anticipated charges for the visit are 2,380. the approved apc payment rate is 780. Where will the patient benefit package be applied? - ANSWERSto the approved APC payment rate pt. has met the 200 ind. deductible and 900 of the 1000 co-ins. resp. the co-ins. rate is 20%. the est. ins. plan respon is 1975. what amt. of co-ins. is due from pt. - ANSWERS which of the following items are considered valid proof of income documents. - ANSWERScopies of paycheck stubs from the recent three months When is a pt. considered to be medically indigent? - ANSWERSpt. outstanding med bills exceed a defined dollar amt or percent of asset what pt assets are considered in the fin assist app - ANSWERSprimary residence if the pt cannot agree to payment arrangments, what is the next best option - ANSWERSwarn pt that unpaid accts are placed w collection agencies for further processing what are numbered receipts for - ANSWERSensure all payments are properly acted for and deposited what is an effective tool to help staff collect payments at time of service - ANSWERSdevelop scripts for the process of requesting payment what must happen to cash, checks, and credit card transactions at the end of each shift

• ANSWERSbalance why is it important to have a high quality standards for reg. - ANSWERSbc quality failures affect the providers Joint Commish results on review day how does utilization review staff use correct ins info - ANSWERSobtain approval for in pt. days and coordinate services

what core fin activities are resolved within pt. access - ANSWERSscheduling, pre-reg, ins verif, mng care process what is an unscheduled direct admission - ANSWERSpt. who is admitted from the physicians office on an urgent basis when is not appro to use an observ status - ANSWERSas a sub for in pt admission pt who require periodic skilled nursing or therapeutic care receive services from what type of program - ANSWERShome health agency type of info that is typically collected during the scheduling contact - ANSWERSpt name, dob, sex, dx, req test/proced, prefer dos, ordering phys, pt tele # every pt who is new to health care provider must be offered what - ANSWERSprinted copy f providers privacy notice which stmnt applies to self insured plans - ANSWERSemployer assumes direct respon and risk for employee healthcare claims info recorded in a 270 transaction - ANSWERSdob process that pt health plan uses to retroact collect payments from liability, auto, or wc - ANSWERSsubrogation why do mnged care plans have agreements w/ hospitals physiciansm and other healthcare providers to offer a range of services to plan members - ANSWERSreduce healthcare costs in what type of pymnt method is lump sum or bndled payment negotiated between payer and some/all providers - ANSWERSpackaged pricing 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 limitations which stmnt applies to private rooms - ANSWERSif med necessity for a private room is docu in chart, pt ins. will be billed diff which true about attempting to collevt pt liability amnts after service - ANSWERSinefficient and results in higher bad debt levels which of the following is true about screening a beneficiary for possible MSP situations - ANSWERSnecessary to ask the pt each of the MSP questions what do MSP disability rules require - ANSWERSpt is younger than 65 yo

NOT true of medicare adv plans - ANSWERSpts who join medicare adv plan will not receive a health ins card from the plan they selected an acceptable way to complete MSP screening for a liability situation - ANSWERSask if the current service is related to an accident which of the following is a valid reason for a payer to deny a claim - ANSWERSfailure to complete auth requirements NOT a possible consequence of selecting the wrong pt in the MPI - ANSWERSclaim is paid in full comprehensive [re-reg data includes which of the following - ANSWERScomplete insurance and emergency contact info which is true of medicare adv plan - ANSWERSa managed care plan for medicare beneficiaries which is not a characteristics of a Medicaid HMO - ANSWERSMedicaid-eligible pts are never required to join a Medicaid HMO plan which stmnt describes APC (ambulatory payment classification) system - ANSWERSAPC rates are calculated on national basis and are wage adjusted by geographic region process does a managed care plan use to determing if health care servces are approp for a pt. condition - ANSWERSauth services beofer they are provided and strictly limit days of in pt. care approved w/out additional clinical info from the provider a violation of EMTALA - ANSWERSregistration staff members routinely contact mnged care plans for prior auth before pt is seen by the on duty physician stmnt is trueof important message from medicare notification requirements - ANSWERSnotification can be issued no earlier than 7 days before admission and no more than 2 days before discharge true stmnt of internal in pt tansfers - ANSWERStransfers are coordinated by the bed- placement coordinator and are not recorded in the system until the pt is moved to the receiving unit and bed what is the self pay balance after insurance - ANSWERSportion of the adjudicated claim that is fure from the patient which of the following is an alternative to valid lonf-term payment plans - ANSWERSbank loans

pt has the following benefit plan: 400 per family member deductible, to max of 1200 per year and 2000 per family member co-ins, toa family max of 6000 per year, excluding the deductible. 5 family memebers are enrolled in this benefit plan. what is the max out of pocket exp that the family can occur during the calender year - ANSWERS type of plan restricts benefits for nonemergency care to approced providers only - ANSWERSA PPO plan what does scheduling allow a provider staff to do - ANSWERSreview the approp of the service requested when an adult pt is covered by both his own and his spouses health ins plan, which of the stmnt is true - ANSWERSpt ins is the primary ins. claim is related to an accident, what must the hospital report - ANSWERScounty in which the accident occured mrs jones, a med beneficiary, was admitted to the hospital on june 20, 2010. as of the admission date, she had only used 8 in pt. days in the current benefit period. if not discharged, on what date will mrs. jones exhaust her full coverage days - ANSWERSAugust 9, 2010 in order to meet eligibility guidlelines for healthcare beneifts, Medicaid beneficiaries must fall into a specified need category and meet what other type of requirment - ANSWERSincome and expense most managed care plans do not permit pt balances billing except for what cirumstances - ANSWERSdeductible and copayments requirements fee for service plans pay claims based on a percentage of charges. how are pt out of pocket costs calculated? - ANSWERSlimited be federal ERISA statues MSP rules allow providers to bill medicare for liability claims after what happens - ANSWERS120 days pass, but claim must be withdrawn from liability carrier what form is used to bill medicare - ANSWERSub- two statutory exclusions from hospice coverage - ANSWERSmedically unnecessary services and custodial care examples of hospital-based physicians - ANSWERSED physicans, radiologist, and pathologists advantage of provider based clinic - ANSWERSability to bill both the technical component and the professional component by the provider

example of a technical denial - ANSWERSexceeding frequency limitations how does financial counseling process begin - ANSWERSexplain the hospitals credit and collection policies and what they mean to the patients hoe does a health pln recover dollars paid for a liability claim from the liability carrier - ANSWERSsubrogation type of acct adjustment results from the pt inability to pay a self balance - ANSWERScharity adjustment according to the department of health and human services guidelines, which of the following is not considered income - ANSWERSsale of property , house, or car what must a provider do to qualify an acct as a medicare bad debt - ANSWERSpursue the acct for 120 days and then refer it to an outside collection agency revenue cycle begins with scheduling a pt. for service and ends with what - ANSWERSarchiving of the fully resolved acct how does increasing the provision for bad debts affect the financial statements - ANSWERSreduces gross receivables and increase operating expense for the period a successful medicare pay for performance initiative will likely result iin what - ANSWERShigher payments while covering sicker beneficiaries what are some component of the charge master - ANSWERSroom charges and detailed ancillary charges using pt specific info, calculate the pt liability for MRI of the right knww. the charge master price based on CPT code for MRI is 2500; the payers contract discount wtht the provider is 20% of the charges; the pt benefit plan deductible of 80/20 with no limit on pt portion was met - ANSWERS how are charges recorded as charity care treated - ANSWERSas a deduction from the revenue that is reported as a footnote to the financial statments what type of utilization review are used to ensure that resources and services are provided in the most efficient and effective ways - ANSWERSprospective review, concurrent review, and retrospective review the situation where neither the pt nor spouse is employed is described to the payer using: - ANSWERSa condition code

regulations and requirements for creating accountable care organizations which allowed providers to beign creating these organization were finalized - ANSWERS what is correct discharge status code for a pt who is discharged to a swing bed unit in the same hospital - ANSWERS what is the primary responsibility of the recovery audit contractor - ANSWERSto correct identity proper payments for medicare part a and b claims