Healthcare Revenue Cycle Management, Exams of Nursing

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Consents are signed as part of the post service process. (True or Flase) - ANSWERSFalse Patient service costs are calculated in the pre-service process for scheduled patients. (True or False) - ANSWERSTrue The patient is scheduled and registered for service is a time of service activity (True or False) - ANSWERSFalse The patient account is monitored for payments is a time of service activity (True or False) - ANSWERSFalse case management and discharge planning service are a post service activity ( True or False) - ANSWERSFalse Sending the bill electronically to the health plan is a time-of-service activity(True or False) - ANSWERSFalse Pre-Service - ANSWERSThe patient is scheduled and registered for service, patient service cost are calculated Time of service - ANSWERSCase management and discharge planning service are provided, consents are signed Post service - ANSWERSBill sent me electronically to health plan, patient accounts is monitored for payment The following statements best describe best practice established by the Medical debt task force. A. Educate patients B. Coordinate to avoid duplicate patient contacts C. Exercise moderate judgment when communicating with providers about scheduled service D. Be consistent in key aspects of account resolution E. Report to healthcare plans when the patient's account is transferred to collection agency F. Follow best practice for communication - ANSWERSA. Educate patients B. Coordinate to avoid duplicate patient contacts D. Be consistent in key aspects of account resolution

F. Follow best practice for communication Which is Not a main HFMA healthcare Dollar & Sense revenue cycle Initiative? A.Patient Financial Communications B.Price Transparency C.Medical Account Resolution D.Process Compliance - ANSWERSD. Process compliance This option refers to a patient financial communications best practice. Annual observation, monitoring, and tracking of results make up the process compliance evaluation required to document compliance with the best practices. This evaluation may be performed by any organization independent of the department that is being audited, such as internal audit, compliance quality, or a third party. The evaluation should be comprehensive and should cover all scenarios addressed by the practices that are relevant to a particular organization. Which option is NOT a department that supports and collaborates with the revenue cycle? A. Information Technology B. Clinical Services C.Finance D. Assisted Living Services - ANSWERSD. Assisted Living Which option is NOT a continuum of care provider? A. Physician B.Health Plan Contracting C. Hospice D. Skilled Nursing Facility - ANSWERSB. Health Plan Contracting Which of the following are essential elements of an effective compliance program? A. Established compliance standards and procedures. B. Designation of a compliance officer employed within the Billing Department. C.Oversight of personnel by high-level personnel. D. Automatic dismissal of any employee excluded from participation in a federal healthcare program. E. Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines. - ANSWERSA.Established compliance standards and procedures. C.Oversight of personnel by high-level personnel. E.Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines. Annually, the OIG publishes a work plan of compliance issues and objectives that will be focused on throughout the following year. Identify which option is NOT a work plan task mentioned in this course. A. Payments to Physicians for Co-Surgery Procedures

B. Denials and Appeals in Medicare Part D C. Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute-Care Transfer Policies D. Standard Unique Employer Identifier - ANSWERSD. Standard Unique Employer Identifier In order to promote the use of correct coding methods on a national basis and prevent payment errors due to improper coding, CMS developed what? A. The Correct Coding Initiative (CCI) B. The Advance Beneficiary Notice of Noncoverage (ABN) C. The Medicare Secondary Payer (MSP) D. Modifiers - ANSWERSA. The correct Coding initiative CCI A staff member receives cash in the mail and does not immediately report the cash to the manager for special handling. This is an example of financial misconduct. True or False - ANSWERSTrue A mother sees a charge on her hospital bill for a circumcision for a newborn girl. This is an example of falsifying medical records to boost reimbursement. True or False - ANSWERSFalse A patient access staff member takes several file folders and highlighters home for personal use. This is an example of theft of property. True FALSE - ANSWERSTrue A physician documents a fictitious epidural in a patient's medical record in an effort to receive additional payment. This is an example of miscoding claims. True or False - ANSWERSFalse Several unauthorized claims are sent to a health plan with the wrong procedure codes. This is an example of overcharging. True or a false - ANSWERSTrue What do business/organizational ethics represent? A. Principles and standards by which organizations operate B. A healthcare provider's practices and principles: C. An employee's actions influenced by experiences and value system D. The patient privacy standard within healthcare - ANSWERSA. Principles and standards by which organizations operate What is the intended outcome of collaborations made through an ACO delivery system? A. To ensure appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients. B. To create cost-containment provisions to reform the healthcare delivery system. C. To reform the healthcare system into a system that rewards greater value, improves the quality of care and increases efficiency in the delivery of services.

D. To provide financial incentives to physicians for reporting quality data to CMS. - ANSWERSA. To ensure appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients. Which of these statements describes the new methodology for the determination of net patient service revenue: 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 explest 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 - ANSWERSC. Net patient service revenue is defined as the total incurred charges, less the explest price concession, less any applicable implicit price concession(s) as applied to the specific portfolio of accounts What are KPIs? 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 - ANSWERSB. Key performance indicators, which set standards for accounts receivable (A/R) and provide a method of measuring the collection and control of A/R. 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? A. Patients in recovery from cardiac or pulmonary disease, stroke or neurological disorders, or orthopedic surgery B. Observation, newborn, Emergency (ED) C. Skilled nursing, hospice, home health and clinic D. People with pulmonary disease, cardiac disease, cancer, and conditions requiring IV therapy or tube feedings

Correct - ANSWERSB. 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: A.Name, date of birth, address and telephone number B. Date of birth, social security number and sex C. Full legal name, date of birth, sex and social security number D. Full legal name, ordering physician, insurance identification number - ANSWERSC. Full legal name, date of birth, sex and social security number Pre-registration is defined as: A. The collection of demographic information, insurance data, financial information, providing reminders, prep information, and identifying the potential need for financial assistance for scheduled patients. B. Using information from the ordering physician's office, creating a new EHR record and visit for all scheduled patients. C. Creating the visit record for all scheduled patients, even if contact to verify information has not been completed prior to service D. Collecting orders from physician offices and entering orders into the EHR system prior to service. - ANSWERSA.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 describe the various Medicare benefit programs: A. Medicare plans A, B and C are all provided and may be mixed and matched according to patient need; Medicare D plans are prescription drugs and home health benefits. B. All Medicare plans (A,B,C and D) are identical, but the carriers vary from state to state C. Medicare A, B, C, and D benefit plans plus D. Medicaid coverages. D.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. - ANSWERSD.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?

A. Medicaid programs in states adopting the Medicaid expansion options under the Affordable Care Act are provided without regard to income levels for permanent residents of the state. B. Medicaid is a federally aided, state operated and administrated program to provide health and long-term care coverage for low income individuals and families. C. Medicaid categories are restricted to children, pregnant women and elderly in nursing homes. D. Medicaid is a federally funded program provided to states based on poverty guidelines. - ANSWERSC. Medicaid categories are restricted to children, pregnant women and elderly in nursing homeS Examples of managed care plans include: A. HMO, PPO and EPO plans B. POS, Concierge plans, Medicare Advantage plans C.Direct contracting for specific services from specific providers D. All of the above - ANSWERSA. HMO, PPO and EPO plans Patient Financial Communications best practices include all of the following activities except: A. Communicating the details of the patient's insurance coverage including eligibility and benefits. B. Collecting payment or initiating the process to immediately remove the patient from the service schedule. C. Discussing unpaid balances and providing financial assistance information, as appropriate. D. Providing financial counseling including assistance with potential Medicaid eligibility processing. Correct - ANSWERSB. 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: A.Total charges and discounts, if any, that may be applicable. B. Insurance eligibility, diagnosis and procedure codes, total estimated charges, adjudication calculations based on average payments from the insurance carrier for the service. C. Insurance coverage and benefits, service or test involved, diagnosis and procedure codes, total estimated charges, adjudication calculations based on the patient's benefit package. D. Chargemaster pricing less the provider's standard discounting amount(s) for hospital services. - ANSWERSC. 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: A. Higher patient satisfaction scores as all paperwork is completed prior to the date of service, resulting in an expedited arrival process when the patient arrives for service. B. Increased patient understanding of the financial responsibility prior to service. C. Opportunity to clarify arrival instructions and time for the day of service. D. Identification of patients who are likely to be "no shows". - ANSWERSD. Identification of patients who are likely to be "no shows". Review Your Knowledge Which patients are considered scheduled? A. Observation Patients B. Emergency Department Patients C. Recurring/Series Patients D. Hospice Care - ANSWERSC. Recurring/Series Patients Name the guideline that Medicare established to determine which diagnoses, signs, or symptoms are payable. A. Patient Identifiers B. Local Coverage Determination C. Advance Beneficiary Notice D. Scheduling Instructions - ANSWERSB. Local Coverage Determination What is the purpose of insurance verification? 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. - ANSWERSB. To ensure accuracy of the health plan information. Which option is a federally-aided, state-operated program to provide health and long- term care coverage? A. Medicare B. Medicald C. Self-Insured Plans D. Liability Coverage - ANSWERSB. Medicald Which option is NOT a specific managed care requirement? A. Referrals B. Notification C. Preferred Provider Organization D. Discharge Planning - ANSWERSC. Preferred Provider Organization

What is the first component of a pricing determination? A. Identify the service or test involved B. Verification of the patient's insurance eligibility and benefits C. Inform the patient that physician services are or are not included D. Use a worksheet or other tool for guidance in determining an estimate - ANSWERSB. Verification of the patient's insurance eligibility and benefits What is the purpose of financial counseling? A. To address the most appropriate ways to conduct financial interactions at every point B. To train staff on how to request payment and conduct conversations C. To educate the patient on his/her health plan coverage and financial responsibility for healthcare services D. To help the patient understand exactly how a contracted health plan will resolve their benefit package - ANSWERSC. To educate the patient on his/her health plan coverage and financial responsibility for healthcare services EMTALA prohibits inquiries about health plan or liability payer information if the inquiry will delay examination or treatment. What other requirements apply to the Emergency Department registration work? A. Patients are initially triaged by medical personnel and a "quick" registration initiated to allow electronic order entry and documentation. B.Identification and verification of insurance eligibility and benefits once the medical screening has been completed. C. No additional registration may occur until the patient is stabilized. D. All of the above. - ANSWERSD All of the above A.Patients are initially triaged by medical personnel and a "quick" registration initiated to allow electronic order entry and documentation. B. Identification and verification of insurance eligibility and benefits once the medical screening has been completed. C. No additional registration may occur until the patient is stabilized. D. All of the above. Typical activities which must be performed when an unscheduled patient arrives for service include: A.Activation of the registration record based on the previous visit information, insurance verification and documentation of patient arrival time. B. "Quick registration" to expedite the arrival process and instructions to return to the registration desk upon completion of service to finalize the registration record and check out of the facility. C. Identification of patient in the MPI or initiation of a new MPI record, insurance verification of eligibility and benefits, managed care screening, medical necessity

screening, price estimation and financial counseling to achieve the appropriate account resolution. D. Initiation of a new MPI record, insurance verification if time permits, managed care screening, price estimation and financial counseling to achieve the appropriate account resolution. Incorrect - ANSWERSC. Identification of patient in the MPI or initiation of a new MPI record, insurance verification of eligibility and benefits, managed care screening, medical necessity screening, price estimation and financial counseling to achieve the appropriate account resolution. Case managers are involved from admission with the discharge planning process. The purpose of discharge planning is: A.To estimate how long the patient will be in the hospital, identify the expected outcome of the hospitalization and initiate any special requirements for services at or after the time of discharge. B. To obtain certification of payment from the patient's insurance plan prior to discharge C. To ensure that the information necessary for the physician's office billing is collected prior to discharge. D. To schedule the days for which concurrent review must be completed and signed off by the attending and referring physicians. Correct - ANSWERSA.To estimate how long the patient will be in the hospital, identify the expected outcome of the hospitalization and initiate any special requirements for services at or after the time of discharge. The chargemaster is basically a list of services, procedures, room accommodations, supplies, drugs, tests, etc. typically associated with the billing for services rendered to patients. Challenges typically associated with the chargemaster include: A. Providing comprehensive education to end users in the service departments. B. Omission of charges, obsolete or invalid codes, and the omission of required modifiers. C. Incorporating specific payer requirements for bundled charges. C.Revisions based on physician practice patterns. - ANSWERSB. Omission of charges, obsolete or invalid codes, and the omission of required modifiers. Ultimately, the services provided in the healthcare system are reduced to standard codes. The primary types of coding systems currently used in healthcare are: A. HIM; HCAPCS B. ICD-9/CPT/HCPCS codes C. ICD-10-CM/ICD-10-PCS; CPT/HCPCS codes D. FASB: ASC 606 - ANSWERSC. ICD-10-CM/ICD-10-PCS; CPT/HCPCS codes There are four code sets that provide health plans with additional information as they process claims. Those code sets are:

A. Condition codes, occurrence codes, occurrence span codes and value codes. B. Condition codes, revenue codes, occurrence codes, and value codes. C. Condition codes, HCPCS codes, value codes, and revenue codes. D. Condition codes, insurance codes, occurrence codes, and value codes. - ANSWERSA. Condition codes, occurrence codes, occurrence span codes and value codes. Each type of service has unique billing rules which come into play during the provision of service. For the skilled nursing facility, care is covered if which of the following factors are present: A. The patient requires skilled nursing or rehabilitation on a weekly or semi-weekly basis. B. The patient required skilled services on a daily basis and those services can only be provided on an inpatient basis in a SNF. C. The patient has not been an inpatient in a hospital for at least 3 calendar days prior to admission to the SNF. D. ICF beds are not available at the time of admission to the SNF. - ANSWERSB. 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: A. An APC designation which is converted into the DRG assignment. That result is then multiplied by the base rate to determine the payment. B. A relative weight which is multiplied by the average national cost of care per DRG to determine payment. C. A cost to charge ratio which is then applied to the payer's base payment rate to determine payment. D. A relative weight which is multiplied by the established base payment rate t 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. - ANSWERSD. A relative weight which is multiplied by the established base payment rate t 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: A. A payment scheme whereby the PPO pays a set percentage of charges. B. 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. C. A discounting scheme whereby the PPO sets a discount amount based on its internal calculations of the value of the care provided. D. A payment scheme which applies APC grouping to determine the cost to charge

ration to be sued in paying claims. - ANSWERSB. 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: A. Payers will waive timely filing denials for claims filed over a year from date of service. B. Traditional Medicare requires that a claim be filed within one year of the date of service. C. Managed care contracts may impose timely filing rules specific to a provider's contract. D. States may set timely filing deadlines for health care claims. - ANSWERSA. Payers will waive timely filing denials for claims filed over a year from date of service. What does EMTALA require hospitals to do? .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. - ANSWERSA. To provide a medical screening examination and stabilizing treatment to every person presenting at an ED and requesting medical evaluation or treatment In what manner do case managers assist revenue cycle staff? 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. - ANSWERSD. 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? 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. - ANSWERSA. To ensure it supports and represents the services provided within the organization.

What is the responsibility of HIM? A. To maintain all patient medical records B. To make information available instantly and securely to authorized users 4-POST SERVICE FINANCIAL Posting Electronic Funds Transfer 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 - ANSWERSA. To maintain all patient medical records What are claim edits? 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 WICE FINANCIAL Funds Transfer ivice (ERA) 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 - ANSWERSC. Rules developed to verify the accuracy and completeness of claims based on each health plan's policies Which statement is NOT a unique billing rule specific to providers? 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-04/837-1, 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 - ANSWERSD. A patient may be balance billed for whatever amount the non-contracting physician charges above the health plan's reimbursement Which of the following statements does not apply to billing during the COVID-19 public health emergency: 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- pandemic.

D. Cost sharing has been waived for testing for COVID-19 in the ED, physician office, urgent care center or other ambulatory location. - ANSWERSB. Telemedicine claims are not payable if the patient conducts the telemedicine visit from home. Which concept is NOT a contracted payment model? A. Stop-Loss Provision B. Percentage Discount C. Per Diem Payment D. Capitation - ANSWERSA. Stop-Loss Provision