Healthcare Revenue Cycle Management, Exams of Nursing

Download Healthcare Revenue Cycle Management and more Exams Nursing in PDF only on Docsity! CRCR EXAM 2023 What do Case Managers do? - Answer Monitor high resource cases to ensure effective utilization What is HIM responsible for? - Answer all pt medical records: transcribe, coding, release to biling, answer requests for documentation What is utilization management responsible for? - Answer manage cases: services correct, on time What are the three types of utilization review? - Answer Prospective, Concurrent, Retrospective Where can home health services be offered? - Answer Home, Assist Living, neighbors: just not SNF nor Hospital To receive -Care payments, what must a SNF have when receiving a pt from a hosp? - Answer A transfer agreement approved by -Care. Can a home health agency employ another agency to provide services? - Answer Yes, so long as at least one employee of the original agency provides care. What is the Net Collection Rate? - Answer how much cash was collected as a % of available to collect? What is the Net Collection Rate benchmark? - Answer 95% What is the benchmark for denials - Answer <2% on first submission Formual for cost to collect - Answer total PFS expenses/gross pt care collections What is the benchmark for cost to collect - Answer 2.25% What % of the UB-04 source of data is from pt access? - Answer 40% What % of the UB-04 source of data is from service depts? - Answer 11% What % of the UB-04 source of data is from HIM? - Answer 20% What % of the UB-04 source of data is from billing? - Answer 20% What % of the UB-04 source of data is not used? - Answer 9% What % of the CMS 1500 source of data is from pt access? - Answer 53% What % of the CMS 1500 source of data is from service? - Answer 14% What % of the CMS 1500 source of data is from HIM - Answer 7% What % of the CMS 1500 source of data is from billing? - Answer 26% CRCR EXAM 2023 From whom is the UB-04 directed? - Answer institutional: hospitals, SNF, hospice From whom is the CMS 1500? - Answer non-institutional: physicians, DME In the FDCA, what is Title I - Answer Truth in Lending Act What is the Truth in Lending Act - Answer 5 points must be triggered (such as interest will be charged), then must disclose APR, total payments, late payment charges, etc. What are the penalties for violating the FDCA? - Answer creditors can be sued Who enforces the FDCA for hospitals? - Answer FTC In the FDCA, what is Title III - Answer limits garnishments In the FDCA, what is Title IV - Answer Fair Credit Reporting Act What is the Fair Credit Reporting Act? - Answer provides consumer rights in reporting loans Are there rules for how a debt collector communicates with debtor? - Answer Yes, eg no profane language, can't contact before 8 AM Is a newborn a scheduled or unscheduled pt - Answer unscheduled What are the three types of pt access incoming to a HCO? - Answer scheduled, unscheduled, recurring What is LCD - Answer local coverage determinants, in absence of NCD, LCD dtermines whether -Care will pay for an item or service What is NCD - Answer national coverage determinants:' nationwide determination of whether Medicare will pay for an item or service What % of pts should be pre-registered of all scheduled pts? - Answer 98% What is the code for HIPAA transaction set for HC eligibility and benefit responses - Answer 270 outgoing 271 response What are some payer data elements needed to process payment? - Answer policy type, covered persons, mail address, cvr type (HMO), deductible What is an PPO - Answer closest to indemnity plan, only preferred doctors in network get contracted prices What is an EPO - Answer exclusive provider - limits services to only EP CRCR EXAM 2023 In Pay for Performance, what must hospitals do in the capitation type initiative? - Answer for chronically ill, must guarantee CMS a savings of at least 5% over similar population What is Pay for Performance? - Answer Pay-for-performance" is an umbrella term for initiatives aimed at improving the quality, efficiency, and overall value of health care. Pay-for-performance has become popular among policy makers and private and public payers, including Medicare and Medicaid. Formula for Net Days in Pt A/R - Answer Net Pt A/R _____________________ Net Revenue/365 (or time period) What does Net Days in Pt A/R tell us? - Answer indication of efficiency of collections, revenue posting, and financial ops of A/R Does Net Days in Pt A/R get aged from date of service, date bill sent, or? - Answer Date of service What is goal for aging A/R >90 days - Answer 15-18% What is goal for aging A/R >1 yr - Answer <1% What is goal for time for charge posting - Answer w/in 1-3 days of service What is goal for credit balance - Answer <1% of billed A/R What is goal for charity and bad debt - Answer 5-8% of billed A/R What should be taken into account when estimating net revenue (for future) - Answer historical adjustments, new payer contracts, charity care, bad debt What are reserves? - Answer how much is not yet collected What is important about reserves - Answer needs to be as accurate as possible - if caught off guard, could impact available funds What % of reserves are self pay bills >120 days from 1st bill - Answer 100% What % of reserves are self pay bills 90-120 days from 1st bill - Answer 50% What % of reserves are self pay bills 60-90 days from 1st bill - Answer 25% What % of reserves are medicare bills >365 days past discharge - Answer 20% What % of reserves are medicare bills 180-365 days past discharge - Answer 10% CRCR EXAM 2023 Are gross charges or contractural amounts posted to a pt's account? - Answer If know contractural amount can post, otherwise post gross charge to pt's account until insurance pays What are instances when -care is a 2ndry payer? - Answer Disability (pt <65, has LGHP), ESRD (in 30 day coordination period), working aged, accident (when no liability exists) What is the correct coding initiative? - Answer the purpose of the CCI is to ensure that the most comprehensive groups of codes are billed, rather than the component parts. developed by CMS What are some ways to avoid problems with cash postings? - Answer large write-offs such as bad debt should be done by managers. What does CMS require when there is a credit balance? - Answer reporting to CMS What does HFMA recommend a HCO do with a small credit to a pt payer? - Answer absorb if pt does not claim after a certain period of time What is a bank lock box? - Answer contracting with a bank to receive, deposit, and electronically report payments from pts and payers What were the four goals of HIPAA passed in 1996? - Answer portability - the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs; Reduces health care fraud and abuse; Mandates industry-wide standards for health care information on electronic billing and other processes; and Requires the protection and confidential handling of protected health information What is APC? - Answer Ambulatory payment classification: United States government's method of paying for facility outpatient services for Medicare. analogous to the Medicare prospective payment system for hospital inpatients (DRG). APCs are an outpatient prospective payment system applicable only to hospitals. What is case rate? - Answer fixed price for specified procedure. Gives provider opportunity to manage costs before capitation. What is a silent PPO - Answer insurance companies that offer providers less payment, invalid discounts (they try to look like a contracted PPO) What is electronic remittance advice 835 data set? - Answer used to send hc claim payments and advice - four levels from receipt (then paper trail) to level 4 - all electronic and links bank. -Care uses level 4. Can a Medicare beneficiary request an appeal? - Answer yes, must be an amount >$130, judicial review if over $1260 CRCR EXAM 2023 Can a provider request a -Care appeal? - Answer yes, must be >$1000; and on Part A, only on medical necess If a beneficiary knew services would not be provided, is he liable for payment? - Answer Yes If neither provider nor beneficiary knew services wouldn't be covered, are they liable? - Answer No, -Care must cover. But must have been reasonable to have not known. If provider should have known services wouldn't be covered and didn't give ABN, are they liable? - Answer Yes What criteria should be used to evaluate a collection agency? - Answer reputation, pt relations, agency fees (they should give an estimated recovery amount), 'no recovery, no fee' What is a rentention account (in regards collection agency)? - Answer Holding trust account where recovered monies are kept until transferred to the provider What is Chpt 7 bankruptcy? - Answer straight bankruptcy What is Chpt 11 bankruptcy? - Answer debtor reorg - bankruptor has continuing management of business, debtor creates plan to reorg, creditors must approve, may also involve reduction in debt amounts What is Chpt 13 bankruptcy? - Answer debt rehab - no liquidation, reorg holdings, creditors look to future earnings (eg garnishment) What is exempt in bankruptcy? - Answer property (like house, personal items), alimony, tools of trade What is exempted from discharge in bankruptcy? - Answer education loans, gvt fines, unpaid alimony/child care, debts arisen from lying FAP (financial assistance program) and its charity agreements? - Answer non-profits will have limitations on charges to uninsured how should a HCO determine poverty guidelines? - Answer Can use the federal poverty guidelines, income does not include capital gain, injury comp, sale of property - and is state defined What is catastrophic charity - Answer in the event of catastrophic injury or illness what is an open insurance balance? - Answer After 60 days, pt must pay or fight with insurance co. to pay (unless prohibitions in contract) what is subrogation? - Answer health plan bills liability insurance Will -Care pay for worker's comp - Answer No