Healthcare Revenue Cycle Management, Exams of Andragogy

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CRCR EXAM MULTIPLE CHOICE, CRCR

Exam Prep, Certified Revenue Cycle

Representative - CRCR (2021) questions

and answers well illustrated.

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

With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what? - correct answer. Access their information and perform functions on-line

What date is required on all CMS 1500 claim forms? - correct answer. onset date of current illness

What does scheduling allow provider staff to do - correct answer. Review appropriateness of the service request

What code is used to report the provider's most common semiprivate room rate? - correct answer. Condition code

Regulations and requirements for coding accountable care organizations, which allows providers to begin creating these organizations, were finalized in: - correct answer. 2012

What is a primary responsibility of the Recover Audit Contractor? - correct answer. To correctly identify proper payments for Medicare Part A & B claims

How must providers handle credit balances? - correct answer. Comply with state statutes concerning reporting credit balance

Insurance verification results in what? - correct answer. The accurate identification of the patient's eligibility and benefits

What form is used to bill Medicare for rural health clinics? - correct answer. CMS 1500

What activities are completed when a scheduled pre-registered patient arrives for service? - correct answer. Registering the patient and directing the patient to the service area

In addition to being supported by information found in the patient's chart, a CMS 1500 claim must be coded using what? - correct answer. HCPCS (Healthcare Common Procedure Coding system)

What results from a denied claim? - correct answer. The provider incurs rework and appeal costs

Why does the financial counselor need pricing for services? - correct answer. To calculate the patient's financial responsibility

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 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

what protocol was developed through the Patient Friendly Billing Project? - correct answer. Provide information using language that is easily understood by the average reader

What technique is acceptable way to complete the MSP screening for a facility situation? - correct answer. Ask if the patient's current services was accident related

What is a valid reason for a payer to delay a claim? - correct answer. Failure to complete authorization requirements

IF outpatient diagnostic services are provided within three days of the admission of a Medicare beneficiary to an IPPS (Inpatient Prospective Payment System) hospital, what must happen to these charges - correct answer. They must be combined with the inpatient bill and paid under the MS-DRG system

What do large adjustments require? - correct answer. Manager-level approval

What items are valid identifiers to establish a patient's identification? - correct answer. Photo identification, date of birth, and social security number

What must a provider do to qualify an account as a Medicare bad debts? - correct answer. Pursue the account for 120 days and then refer it to an outside collection agency

What restriction does a managed care plan place on locations that must be used if the plan is to pay for the services provided? - correct answer. Site-of-service limitation

What is an example of an outcome of the Patient Friendly Billing Project? - correct answer. Redesigned patient billing statements using patient-friendly language

What statement describes the APC (Ambulatory payment classification) system? - correct answer. APC rates are calculated on a national basis and are wage-adjusted by geographic region

What is a benefit of insurance verification? - correct answer. Pre-certification or pre- authorization requirements are confirmed

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

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

Value - correct answer. The quality of a healthcare service in relation to the total price paid for the service by care purchasers

What areas does the code of conduct typically focus on? - correct answer. Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations

FERA - correct answer. Fraud Enforcement and Recovery act

ESRD - correct answer. End-stage renal disease. The patient has permanent kidney failure, is covered by a GHP, and has not yet completed the 30-month coordination period

What is the purpose of a compliance program? - correct answer. Mitigate potential fraud and abuse in the industry-specific key risk areas

What is important about an effective corporate compliance program? - correct answer. A program that embodies many elements to create a program that is transparent, clearly articulated and emphasized at all employee levels as a seriously held personal and organizational responsibility, one that relies on full communication inside and outside the organization

What is a CCO - correct answer. Chief compliance officer - they typically report directly to the board of directors/trustees as well as the chief executive officer, and has limited responsibilities for other operational aspects of the organization

What are the situations where another payer may be completely responsible for payment? - correct answer. Work-related accidents, black lung program services, patient is enrolled in Medicare Advantage, Federal grant programs

Under Medicare rules, certain outpatient services that are provided within three days of the admission date, by hospitals or by entities owned or controlled by hospitals, must be billed as part of an inpatient stay. - correct answer. TRUE

The OIG has issued compliance guidance/model compliance plans for all of the following entities: - correct answer. hospices. physician practices. ambulance providers

Providers who are found to be in violation of CMS regulations are subject to: - correct answer. Corporate integrity agreements

What MSP situation requires LGHP - correct answer. Disability

The disadvantages of outsourcing include all of the following EXCEPT: a) The impact of customer service or patient relations b) The impact of loss of direct control of accounts receivable services c) Increased costs due to vendor ineffectiveness d) Reduced internal staffing costs and a reliance on outsourced staff - 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 healthcare services, that together with other information, help define the value of those services and enable consumers to

a) Identify, compare, and choose providers that offer the desired level of value b) Customize health care with a personally chosen mix of providers c) Negotiate the cost of health plan premiums

d) Verify the cost of individual clinicians - correct answer. A

Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons based on a monthly fee is known as a a) MSO b) HMO c) PPO d) GPO - correct answer. B

In a Chapter 7 Straight Bankruptcy filing

a) The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt b) The court liquidates the debtor's nonexempt property, pays creditors, and begins to pay off the largest claims first. All claims are paid some portion of the amount owed c) The court vacates all claims against a debtor with the understanding that the debtor may not apply for credit without court supervision d) The court establishes a creditor payment schedule with the longest outstanding claims paid first - correct answer. A

The core financial activities resolved within patient access include:

a) Scheduling, pre-registration, insurance verification and managed care processing b) Scheduling, insurance verification, clinical discharge processing and payment posting of point of service receipts c) Scheduling, registration, charge entry and managed care processing d) Scheduling, pre-registration, registration, medical necessity screening and patient refunds - correct answer. A

Which of the following is NOT contained in a collection agency agreement?

a) A clear understanding that the provider retains ownership of any outsourced activities b) Specific language as to who will pay legal fees, if needed c) An annual renewal clause d) A mutual hold-harmless clause - correct answer. D

Maintaining routine contact with the health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of:

a) Patient Accounts b) Managed Care Contract Staff c) HIM staff d) Case Management - correct answer. D

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

The nuanced data resulting from detailed ICD-10 coding allows senior leadership to work with physicians to do all of the following EXCEPT:

a) Drive significant improvements in the areas of quality and the patient experience b) Embrace new reimbursement models c) Improve outcomes d) Obtain higher compensation for physicians - correct answer. D

Duplicate payments occur:

a) When providers re-bill claims based on nonpayment from the initial bill submission b) When service departments do not process charges with the organization's suspense days c) When the payer's coordination of benefits is not captured correctly at the time of patient registration d) When there are other healthcare claims in process and the anticipated deductibles and co-insurance amounts still show open but will be met by the in-process claims - correct answer. a

The Affordable Care Act legislated the development of Health Insurance Exchanges,

where individuals and small businesses can

a) Purchase qualified health benefit plans regardless of insured's health status b) Obtain price estimates for medical services c) Negotiate the price of medical services with providers d) Meet federal mandates for insurance coverage and obtain the corresponding tax deduction - correct answer. A

The most common resolution methods for credit balances include all of the following EXCEPT:

a) Designate the overpayment for charity care b) Submit the corrected claim to the payer incorporating credits c) Either send a refund or complete a takeback form as directed by the payer d) Determine the correct primary payer and notify incorrect payer of overpayment - correct answer. A

EFT (electronic funds transfer) is

a) An electronic claim submission b) The record of payments in the hospital's accounting system c) An electronic confirmation that a payment is due d) An electronic transfer of funds from payer to payee - correct answer. D

Revenue cycle activities occurring at the point-of-service include all of the following EXCEPT:

a) The monitoring of charges b) The provision of case management and discharge planning services c) Providing charges to the third-party payer as they are incurred d) The generation of charges - correct answer. C

Medicare beneficiaries remain in the same "benefit period" a) Up to hospitalization discharge b) Until the beneficiary is "hospitalization and/or skilled nursing facility-free" for 60 consecutive days c) Each calendar year d) Up to 60 days - 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 b) Condition has not been discussed during the shift change report meeting c) Pharmacy orders to the ICU have not been entered in the pharmacy system d) Transfer from ICU (intensive care unit) to the Medical/Surgical floor is not reflected in the registration system - correct answer. D

Which of the following is required for participation in Medicaid? a) Meet income and assets requirements b) Meet a minimum yearly premium c) Be free of chronic conditions

d) Obtain a health insurance policy - correct answer. A

HFMA best practices call for patient financial discussions to be reinforced

a) By issuing a new invoice to the patient b) By copying the provider's attorney on a written statement of conversation c) By obtaining some type of collateral d) By changing policies to programs - correct answer. B

A Medicare Part A benefit period begins: a) With admission as an inpatient b) The first day in which an individual has not been a hospital inpatient not in a skilled nursing facility for the previous 60 days c) Upon the day the coverage premium is paid d) Immediately once authorization for treatment is provided by the health plan - correct answer. A

If further treatment can only be provided in a hospital setting, the patient's condition cannot be evaluated and/or treated within 24 hours, or if there is not an anticipation of improvement in the patient's condition with 24 hours, the patient a) Will remain in observation for up to 72 hours after which the patient is admitted as an inpatient b) Will be admitted as an inpatient c) Will be discharged and if needed, designated to a priority one outpatient status d) Will have his/her case reviewed by the attending physician, a consulting physician and the primary care physician and a future course of care will then be determined - correct answer. B

It is important to have high registration quality standards because a) Incomplete registrations will trigger exclusion from Medicare participation b) Incomplete registrations will raise satisfaction scores for the hospital c) Inaccurate registration may cause discharge before full treatment is obtained d) Inaccurate or incomplete patient data will delay payment or cause denials - correct answer. D

Medicare will only pay for tests and services that a) Constitute appropriate treatment and are fairly priced b) Have solid documentation c) Can be demonstrated as necessary d) Medicare determines are "reasonable and necessary" - correct answer. D

Room and bed charges are typically posted a) From case management reports generated for contracted payers b) Through the case management daily resource report c) At the end of each business day d) From the midnight census - correct answer. D

The process of creating the pre=registration record ensures a) Ability to pursue extraordinary collection activities b) Early and productive communication with a third-party payer c) Accurate billing d) That access staff will have the compete and valid information needed to finalize any remaining pre-access activities - 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 d) That reorganizes a debtor's holdings and instructs creditors to look to the debtor's future earnings for payment - correct answer. D

HFMA's patient financial communication best practices specify that patients should be told about the types of services provided and

a) A satisfaction survey regarding clinical service providers b) The price of service to their covering health plan c) The service providers that typically participate in the service, e.g., radiologists, pathologists, etc. d) An expiration of why a specific service is not provided - correct answer. C

The important Message from Medicare provides beneficiaries information concerning their

a) Understanding of billing issues and the deductibles and/or co-insurance due for the current visit b) Right to refuse to use lifetime reserve days for the current stay c) Right to appeal a discharge decision if the patient disagrees with the plan d) Obligation to reimburse the hospital for any services not covered by the Medicare program - correct answer. C

All of the following are potential causes of credit balances EXCEPT

a) Duplicate payments b) Primary and secondary payers both paying as primary c) Inaccurate upfront collections based on incorrect liability estimates d) A patient's choice to build up a credit against future medical bills - correct answer. D

Medicare Part B has an annual deductible, and the beneficiary is responsible for

a) A co-insurance payment for all Part B covered services b) Physicians office fees c) Tests outside of an inpatient setting d) Prescriptions - correct answer. A

The importance of medical records being maintained by HIM is that the patient records a) Are the primary source for clinical data required for reimbursement by health plans and liability payers b) Are the strongest evidence and defense in the event of a Medicare audit c) Are evidence used in assessing the quality of care

d) Are the evidence cited in quality review - correct answer. A

A decision on whether a patient should be admitted as an inpatient or become an outpatient observation patient requires medical judgments based on all of the following EXCEPT

a) The patient's home care coverage b) Current medical needs c) The likelihood of an adverse event occurring to the patient d) The patient's medical history - correct answer. A

Medicare has established guidelines called the Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) that establish

a) Provider and physician reimbursement for specific diagnoses and tests b) Prospective Medicare patient financial responsibilities for a given diagnosis c) Reasonable and customary prices for services in a given area d) What services or healthcare items are covered under Medicare - 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