Healthcare Revenue Cycle Management, Exams of Nursing

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HFMA CRCR EXAM 2024/2025 WITH 100% ACCURATE SOLUTIONS Through what document does a hospital establish compliance standards? - Precise Answer ✔✔code of conduct What is the purpose OIG work plant? - Precise Answer ✔✔Identify Acceptable compliance programs in various provider setting If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - Precise Answer ✔✔Non-diagnostic service provided on Tuesday through Friday What does a modifier allow a provider to do? - Precise Answer ✔✔Report a specific circumstance that affected a procedure or service without changing the code or its definition 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 - Precise Answer ✔✔They must be billed separately to the part B Carrier what is a recurring or series registration? - Precise Answer ✔✔One registration record is created for multiple days of service What are nonemergency patients who come for service without prior notification to the provider called? - Precise Answer ✔✔Unscheduled patients Which of the following statement apply to the observation patient type? - Precise Answer ✔✔It is used to evaluate the need for an inpatient admission which services are hospice programs required to provide around the clock patient - Precise Answer ✔✔Physician, Nursing, Pharmacy Scheduler instructions are used to prompt the scheduler to do what? - Precise Answer ✔✔Complete the scheduling process correctly based on service requeste The Time needed to prepare the patient before service is the difference between the patients arrival time and which of the following? - Precise Answer ✔✔Procedure time Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: - Precise Answer ✔✔Documentation of the medical necessity for the test What is the advantage of a pre-registration program - Precise Answer ✔✔It reduces processing times at the time of service What date are required to establish a new MPI(Master patient Index) entry - Precise Answer ✔✔The responsible party's full legal name, date of birth, and social security number Which of the following statements is true about third-party payments? - Precise Answer ✔✔The payments are received by the provider from the payer responsible for reimbursing the provider for the patient's covered services. Which provision protects the patient from medical expenses that exceed the pre-set level - Precise Answer ✔✔stop loss what documentation must a primary care physician send to HMO patient to authorize a visit to a specialist for additional testing or care? - Precise Answer ✔✔Referral Under EMTALA (Emergency Medical Treatment and Labor Act) regulations, the provider may not ask about a patient's insurance information if it would delay what? - Precise Answer ✔✔Medical screening and stabilizing treatment Which of the following is a step in the discharge process? - Precise Answer ✔✔Have a case management service complete the discharge plan Which is the following is not a characteristic of Medicaid HMO plan? - Precise Answer ✔✔Medicaid- eligible patients are never required to join a Medicaid HMO plan Which of the following is violation of the EMTALA ? - Precise Answer ✔✔Registration staff members routinely contact managed care plans for prior authorizations before the patients is seen by the on duty physician Which of the following statements is true of the important message from Medicare notification requirements? - Precise Answer ✔✔Notification can be issued no earlier than 7 days before admission and no more than 2 days before discharge. What is the self pay balance after insurance - Precise Answer ✔✔The portion of the adjudicated claim that is due from the patient Which of the following options is an alternative to valid long term payment plans - Precise Answer ✔✔Bank loans The patient has the following benefit plan $400 per family member deductible, to a maximum of $1200 per year and $2000 per family member co insurance, to a family maximum of $6000 per year excluding the deductible . Five family members are enrolled in this benefit plan. What is the maximum out of pocket expense that that family could incur during the calendar year? - Precise Answer ✔✔$6000 What type of plan restricts benefits for non-emergency care to approve providers only? - Precise Answer ✔✔A POS (point of service )plan What does scheduling allow provider staff to do? - Precise Answer ✔✔Review the appropriateness of the service requested When an adult patient is covered by both his own and his spouse health insurance plan, which of the statements is true? - Precise Answer ✔✔The patients insurance plan is primary Mrs. Jones , a Medicare beneficiary was admitted to the hospital on June 20,2010. As of the admission date, she had only used 8 inpatient days in the current benefit period. If she is not discharge on what date will Mr jones exhaust her full coverage days. - Precise Answer ✔✔August 9, 2010 In order to meet eligibility guidelines for healthcare benefits, Medicaid beneficiaries must fall into a specified need category and meet what other types of requirements - Precise Answer ✔✔Income and assets Fee for service plans pay claims based on a percentage of charges. How are patients out of pocket cost calculated? - Precise Answer ✔✔They are calculated quarterly Indemnity plans usually reimburse what? - Precise Answer ✔✔A certain percentage of charges after patient meets policy's annual deductible. Departments that need to be included in Charge master maintenance include all EXCEPT - Precise Answer ✔✔Quality Assurance Using HIPPA standardized transaction sets allow providers to: - Precise Answer ✔✔Submit a standardized transaction to any of the health plans with which it conducts business. Which of the following is NOT included in the standardized quality measures? - Precise Answer ✔✔Cost of services The ACO investment model will test the use of pre-paid shared savings to: - Precise Answer ✔✔Encourage new ACOs to form in rural and underserved areas. Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons on a monthly fee is known as: - Precise Answer ✔✔HMO Ambulance services are billed directly to the health plan for: - Precise Answer ✔✔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. Any provider that has filed a timely cost report may appeal in an adverse final decision received from the Medicare Administrative Contractor (MAC), the appeal may be filed with: - Precise Answer ✔✔The Provider Reimbursement Review Board. For scheduled payments, important revenue cycle activities in the time-of-service stage DO Not include: - Precise Answer ✔✔Obtaining or updating patient and guarantor information Hospital can only convert an inpatient case to observation if: - Precise Answer ✔✔The hospital utilization review committee determines before the patient is discharged and prior to billing that an observation setting would be more appropriate. Hospital need which of the following information sets to assess a patient's financial status? - Precise Answer ✔✔Demographic, Income, Assets and Expenses. HIPAA privacy rules require covered entities to take all, of the following actions EXCEPT: - Precise Answer ✔✔Use only designated software platforms to secure patient date. When Recovery Audit Contractors (RAC) identify improper payments as overpayment. the claims processing contractor must: - Precise Answer ✔✔Send a demand letter to the provider to recover the over payment amount. Which HIPPA transaction set provides electronic processing of 8insurance verification requests and responses? - Precise Answer ✔✔The 270-271 set 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: - Precise Answer ✔✔Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow. A scheduled inpatient represents an opportunity for the provider to do which of the following? - Precise Answer ✔✔Complete registration and insurance approval before service The Medicare Bundled Payments for Care Initiative (BCP) is designed to: - Precise Answer ✔✔Align incentives between hospitals, physicians, and non-physician providers in-order to better coordinate patient care. The first and most critical step in registering a patient, whether scheduled or unscheduled is: - Precise Answer ✔✔Verifying the patient's identification The standard claim form used for the billing by hospitals, nursing facilities, and other inpatient services is called the: - Precise Answer ✔✔UB-04 A four-digit number code established by the National Uniform Billing Committee (NUBC) that categorizes/classifies a line in the charge master is known as: - Precise Answer ✔✔Revenue codes Internal controls addressing coding and reimbursement charges are put in place to guard against: - Precise Answer ✔✔Compliance fraud by "upcoding" The 501(R) regulations require non-for-profit providers (501) ©(3) organizations to do which of the following activities: - Precise Answer ✔✔Complete a community needs assessment and develop a discount program for patient's balances after insurance payment During pre-registration, a search for the patient's MRI number is initiated using which of the following data sets: - Precise Answer ✔✔Patient's full legal name and date of birth or the patient's Social Security number To maximize the value derived from customer complaints, all consumer complaints should be: - Precise Answer ✔✔Tracked and shared to improve the customer experience The Business ethics, or organizational ethics represent: - Precise Answer ✔✔The principles and standards by which organizations operate Providers are advised that it is best to establish patient financial responsibility and assistance policies and make sure they are followed internally and by: - Precise Answer ✔✔Third-party payers The advantage to using a third-part, collection agency includes all of the following EXCEPT: - Precise Answer ✔✔Providers pay pennies on each dollar collected. Local Coverage Determination (LCD) and National Coverage Determinations (NCD) are Medicare established guidelines used to determine: - Precise Answer ✔✔Which diagnosis, signs, or symptoms are reimbursable Claims with the dates of service received later than one calendar year beyond the date of service will be: - Precise Answer ✔✔Denied by Medicare in the pre-service stage, the requested service is screened for medical necessity, health plan coverage and benefits are verified and: - Precise Answer ✔✔Pre-authorization are obtained For scheduled patients, important revenue cycle activities in the time-of -service stage DO NOT include: - Precise Answer ✔✔Final bill is presented for payment If a medical service authorization, who is typically responsible for obtaining the authorization: - Precise Answer ✔✔The provider scheduling Concurrent review and discharge planning - Precise Answer ✔✔Occurs during service The fundamental approach in managing denials is: - Precise Answer ✔✔To analyze the type and sources of denials and consider process changes to eliminate further denials The first thing a health plan does when processing a claim is: - Precise Answer ✔✔Check if the patient is a health plan beneficiary and what is the coverage Outsourcing options should be evaluated as - Precise Answer ✔✔Any other business service purchase Insurance verification results in which of the following: - Precise Answer ✔✔The accurate identification of the patient's eligibility and benefits EMTLA and HFMA best practices specify that in an Emergency Department setting: - Precise Answer ✔✔No patient financial discussions should occur before a patient is screened and stabilized he HCCAHPS (Hospital Consumer Assessment of Healthcare Provider's and Systems) initiative was launched to: - Precise Answer ✔✔Provide a standardized method for evaluation patients' perspective on hospital care All of the following are potential causes of credit balances EXCEPT: - Precise Answer ✔✔A patient's choice to build up a credit against future medical bills Medicare will only pay for tests and services that: - Precise Answer ✔✔Can be demonstrated as necessary This 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: - Precise Answer ✔✔Joint Commission for Acceleration of Healthcare Organizations (JCAHO) safety standards It is important to calculate reserves to ensure: - Precise Answer ✔✔A stable financial operations and accurate financial reporting An advantage of a pre-registration program in - Precise Answer ✔✔The opportunity to reduce processing times at the time of service To be eligible for Medicaid, an individual must: - Precise Answer ✔✔Meet income and asset requirements The patient discharge process begins when: - Precise Answer ✔✔The physician writes the order Appropriate training for patient financial counseling staff must cover all of the following EXCEPT: - Precise Answer ✔✔Documenting the conversation in the medical records Patients should be informed that costs presented in a price estimation may: - Precise Answer ✔✔Only determine the percentage of the total that the patients is responsible for and not the actual cost. Any healthcare insurance plan that providers or insures comprehensive health maintenance and services for an enrolled group of persons based on a monthly fee is known as a - Precise Answer ✔✔HMO Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - Precise Answer ✔✔Birthday What customer service improvements might improve the patient accounts department? - Precise Answer ✔✔Holding Staff accountable for customer service during performance reviews What is an ABN(Advance Beneficiary Notice of Non-coverage) required to do? - Precise Answer ✔✔Inform Medicare beneficiary that Medicare may not pay for the order or service What is the initial hospice benefit? - Precise Answer ✔✔Two 90-day periods and an unlimited number of subsequent periods How should a provider resolve a late-charge credit posted after an account is billed? - Precise 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 - Precise Answer ✔✔They are not being processed in a timely manner What are the two statutory exclusions from hospice coverage? - Precise Answer ✔✔Medically Unnecessary services and custodial care What statement applies to the scheduled outpatient? - Precise Answer ✔✔The services do not include an overnight stay How is a mis-posted contractual allowance resolved? - Precise 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 patients need for inpatient care? - Precise Answer ✔✔Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - Precise 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 feild 0 - Precise Answer ✔✔When the patient is insured If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - Precise 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? - Precise Answer ✔✔Disclosure rules for consumer credit sales and consumer loans What is a principle diagnosis? - Precise Answer ✔✔Primary reason for the patients admission Collecting patient liability dollars after service leads to what? - Precise Answer ✔✔Lower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - Precise 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 service? - Precise Answer ✔✔Inpatient care What code indicates the disposition of the patient at the conclusion of service? - Precise Answer ✔✔Patient discharge status code What are hospitals required to do for Medicare credit balance accounts? - Precise 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? - Precise Answer ✔✔Patient With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what? - Precise Answer ✔✔Access their information and perform functions on-line What date is required on all CMS 1500 claim forms? - Precise Answer ✔✔onset date of current illness What code is used to report the provider's most common semiprivate room rate? - Precise Answer ✔✔Condition code Regulations and requirements for coding accountable care organizations which allows providers to begin creating these organizations were finalized in - Precise Answer ✔✔2012 What is a primary responsibility of the recover audit contractor? - Precise Answer ✔✔To correctly identify proper payments for Medicare part A and B claims How must providers handle credit balances? - Precise Answer ✔✔Comply with state statutes concerning reporting credit balance What activities are completed when a scheduled pre-registered patient arrives for service? - Precise Answer ✔✔Registering the patient and directing the patient to the service area In addition to being supported by information found in the patients chart, a CMS 1500 claim must be coded using what? - Precise Answer ✔✔HCPCS What results from a denied claim? - Precise Answer ✔✔The provider incurs rework and appeal costs