Healthcare Revenue Cycle Management: Questions and Answers, Exams of Nursing

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CRCR (2024) Questions and Answers Graded

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Sending the bill electronically to the health plan is a time-of-service activity - SOLUTION True

**False

What happens during the post-service stage? - SOLUTION **A. Final coding of all services,

preparation and submission of claims, payment processing and balance billing and resolution. B. Orders are entered, results are reported, charges are generated, and diagnostic and procedural coding is initiated. C. The encounter record is generated, and the patient and guarantor information is obtained and/or updated as required. D. The focus is on the patient and his/her financial care, in addition to the clinical care provided for the patient. The following statements describe best practices established by the Medical Debt Task Force. Check the

box next to the True statements - SOLUTION **Educate Patients

**Coordinate to avoid duplicate patient contacts Exercise moderate judgement when communicating with providers about scheduled services **Be consistent in key aspects of account resolution Report to healthcare plans when the patient's account is transferred to collection agency **Follow best practices for communication

Which option is NOT a main HFMA Healthcare Dollars & Sense® revenue cycle initiative? - SOLUTION

A. Patient Financial Communications

B. Price Transparency C. Medical Account Resolution **D. Process Compliance

What is the objective of the HCAHPS initiative? - SOLUTION **A. To provide a standardized method

for evaluating patients' perspective on hospital care. B. To provide clear communication and good customer service, which will give the provider a competitive edge. C. To conduct evaluations concerning patients' perspective on hospital care. D. To make certain that during registration key information is verified by means of a picture ID and an insurance card. Which option is NOT a department that supports and collaborates with the revenue cycle? -

SOLUTION A. Information Technology

B. Clinical Services C. Finance **D. Assisted Living Services

Which option is NOT a continuum of care provider? - SOLUTION A. Physician

**B. Health Plan Contracting C. Hospice D. Skilled Nursing Facility

Which of the following are essential elements of an effective compliance program? - SOLUTION

**Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines

**Established compliance standards and procedures Automatic dismissal of any employee excluded from participation in a federal healthcare program **Designation of a compliance officer employed within the Billing Department **Oversight of personnel by high-level personnel. 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. -

SOLUTION 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 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? - SOLUTION **A. The Correct Coding Initiative (CCI)

B. The Advance Beneficiary Notice of Noncoverage (ABN) C. The Medicare Secondary Payer (MSP) D. Modifiers Indicate if the activity is described by the appropriate description of the violation involved: -

SOLUTION True - A staff member receives cash in the mail and does not immediately report the

case to the manager for special handling. This is an example of financial misconduct False - 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 - A patient access staff member takes several file folders and highlighters home for personal use. This is an example of theft of property. False - 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 - Several unauthorized claims are sent to a health plan with the wrong procedure code. This is an example of overcharging.

What do business/organizational ethics represent? - SOLUTION **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

What is the intended outcome of collaborations made through an ACO delivery system? - SOLUTION

**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. Which of these statements describes the new methodology for the determination of net patient service

revenue: - SOLUTION 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 explicit 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.

What are KPIs? - SOLUTION 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 service/discharge 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? - SOLUTION 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? - SOLUTION Full legal name,

date of birth, sex and social security number

Pre-registration is defined as: - SOLUTION 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

describes the various Medicare benefits programs: - SOLUTION 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? - SOLUTION Medicaid

categories are restricted to children, pregnant women and elderly in nursing homes.

Examples of managed care plans include: - SOLUTION All of the above

Patient Financial Communications best practices include all of the following activities except: -

SOLUTION 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? -

SOLUTION 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: -

SOLUTION Identification of patients who are likely to be "no shows".

Which patients are considered scheduled? - SOLUTION A. Observation Patients

B. Emergency Department Patients **C. Recurring/Series Patients D. Hospice Care Name the guideline that Medicare established to determine which diagnoses, signs, or symptoms are

payable. - SOLUTION A. Patient Identifiers

**B. Local Coverage Determinations C. Advance Beneficiary Notice D. Scheduling Instructions

What is the purpose of insurance verification? - SOLUTION 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. Which option is a federally-aided, state-operated program to provide health and long-term care

coverage? - SOLUTION A. Medicare

**B. Medicaid C. Self-Insured Plans D. Liability Coverage

Which option is NOT a specific managed care requirement? - SOLUTION A. Referrals

B. Notification **C. Preferred Provider Organization D. Discharge Planning

What is the first component of a pricing determination? - SOLUTION 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

The correct sequential order of the financial counseling steps for an uninsured patient's surgery case are:

• SOLUTION Greet patient and give your name Explain organization's financial care approach and patient's financial responsibility Review patient's health plan benefits and status Review anticipated charges and patient's anticipated liability Ask patient to resolve liability by reviewing payment options For uninsured, explain financial assistance options

What is the purpose of financial counseling? - SOLUTION 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 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? - SOLUTION ALL of the above

Typical activities which much be performed when an unscheduled patient arrives for service include: -

SOLUTION 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: - SOLUTION 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 billing for services rendered to patients. Challenges typically associated with the

chargemaster include: - SOLUTION 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: - SOLUTION 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: - SOLUTION 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: - SOLUTION

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: - SOLUTION A relative weight which is

multiplied by the established base payment rate to 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: - SOLUTION 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: - SOLUTION Payers will

waive timely filing denials for claims filed over a year from date of service.

What does EMTALA require hospitals to do? - SOLUTION **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.

In what manner do case managers assist revenue cycle staff? - SOLUTION 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.

Why is it critical that a chargemaster is reviewed and updated regularly? - SOLUTION **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.

What is the responsibility of HIM? - SOLUTION **A. To maintain all patient medical records

B. To make information available instantly and securely to authorized users 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

What are claim edits? - SOLUTION 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 **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

Which statement is NOT a unique billing rule specific to providers? - SOLUTION 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-I, 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 amount.

Which of the following statements does not apply to billing during the COVID-19 public health

emergency: - SOLUTION 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-19 pandemic. D. Cost sharing has been waived for testing for COVID-19 in the ED, physician office, urgent care center or other ambulatory location.

What is the sequential order for a Silent PPO scheme? - SOLUTION The patient's claims is sent to the

listed primary insurance carrier The patient's insurance company (a silent PPO) runs the healthcare provider's tax ID number through a PPO discount database or provides a repricing company a copy of the claim After a successful "hit", the claim is "re-priced" based on the PPO discounts that were accessed. After applying the discount, the silent PPO states on the EOB that the healthcare provider agreed to reduce your bill based on your contract with the PPO The medical provider accepts the health plan's statement on the EOB and writes the discount off-never knowing that the discount was invalid.

Which concept is NOT a contracted payment model? - SOLUTION **A. Stop-Loss Provision

B. Percentage Discount C. Per Diem Payment D. Capitation

Credit balances may be created by any of the following activities except: - SOLUTION Credits to

pharmacy charges posted before the claim final bills Which of the following statements represent common reasons for inpatient claim denials? -

SOLUTION Failure to obtain a required pre-authorization; failure to complete a continued stay

authorization and services provided which were not medically necessary. A 68 year old patient, a Medicare beneficiary, was in a car accident. A medical insurance claim was filed with the auto insurance carrier. Six months later this claim remains unpaid. How can the provider

pursue payment from Medicare? - SOLUTION The provider must first bill the auto insurer; however,

after a period of 120 days, if the claim remains unpaid, the provider may cancel the liability claim and bill Medicare.

The difference between bad debt and financial assistance (charity) is: - SOLUTION Bad debt

represents a refusal to pay; charity represents an inability to pay

In order to qualify for financial assistance, a patient or guarantor should: - SOLUTION Provide the

following documents: prior year tax return, employment check stubs from the prior three months and bank statements for the prior three months. To comply with the requirements of Section 501(r) for tax-exempt hospitals chartered as 510(c)

providers, the hospital must complete which of the following activities: - SOLUTION A community

needs assessmenets

The three types of bankruptcy as defined in the 1979 Bankruptcy Act are: - SOLUTION Chapter 7 -

Straight Bankruptcy, Chapter 11- Debtor Reorganization and Chapter 13- Debtor Rehabilitation Which of the following medical debt collection practices are recommended as part of HFMA's Best

Practices for medical account resolution: - SOLUTION Establish policies and ensure that they

are followed

Organizations may opt to contract with or outsource to specific vendors for some or all components of revenue cycle processing. This practice has both advantages and disadvantages. Which of the following

statements is NOT an advantage of utilizing an outsourcing vendor? - SOLUTION The need for legal

review if the outside vendor's staff represents themselves as employees of the healthcare facility. Each hospital covered by the 501(r) regulations is required to develop a financial assistance policy.

Which of the following elements is NOT a required element of the policy? - SOLUTION The notice

that individuals eligible for financial assistance under this policy may be charged more that the amount generally billed (AGB) to insured patients.

Place the daily reconciliation process steps in the correct sequential order: - SOLUTION Obtain

totals of all payments - cash, check, credit card, and debit card Divide remittances into batches and obtain a second total of the electronic remittance advices by payment and contractual allowances Endorse checks immediately. Prepare the bank deposit for all payments. Separate cash payments and contractual adjustments into separate batches and use separate payments and adjustment codes. Post unidentified payments to an unidentified cash account (deposit everything, do not hold unidentified payments) Balance and post batches. Balance payments to the bank deposit. Balance the bank deposit to the general ledger.

Sue Smith came into the hospital. Her insurance provider sent an EFT directly into the hospital's account at the bank. John, the hospital representative, receives an electronic Level 2 ERA. What should he do

next? - SOLUTION **A. Manually match the ERA to the patient account.

B. Nothing unless there is an error.

What is EFT? - SOLUTION **A. The electronic transfer of funds from payer to payee through the

banking system. B. The establishment of internal audits by personnel outside the involved department. C. A standardized healthcare claim payment/advice known as the 835 format. D. A process that requires the separation of duties when processing patient payments.

Which statement is false regarding credit balances? - SOLUTION A. A small credit policy should be

matched by a similar policy for small debit balances. B. Tracking reports should be developed to identify internal charge credits versus external charge credits. C. Hospital generated statements should be sent to patients regarding small credit balances. **D. There are no CMS hospital compliance requirements regarding credit balances.

Which option is NOT a type of denial? - SOLUTION A. Technical

B. Clinical C. Underpayment **D. Contractual Adjustment

Which option is NOT a lien type? - SOLUTION A. Judicial

**B. Subrogation C. Statutory D. Agreement (Consensus)

Based on what you have just read, which activity is not considered when initiating self-pay follow-up

and account resolution activities? - SOLUTION A. Poverty Guidelines

B. Financial Profile C. Presumptive Financial Assistance Determination **D. Patient Open Balance Billing

Which option is NOT a required component of a FAP? - SOLUTION A. Eligibility criteria

B. Application process C. Application assistance **D. Out-of-network providers

Which option is NOT a bankruptcy type governed by the 1979 Bankruptcy Act? - SOLUTION A.

Straight bankruptcy B. Debtor reorganization **C. Creditor priority D. Debtor rehabilitation

Which evaluation criteria demonstrates reputation expectations: - SOLUTION A. The agency's Yelp

score and consumer comments. B. The amount of monies collected monthly. **C. The employment of staff who have documented experience working in financial areas of health care. D. The high turnover rate for entry level employees.

Agency fees are: - SOLUTION A. Paid by patients.

**B. The cost to the provider for collection agency monies offset by the return on baddebt accounts. C. Only reported annually to the provider.

D. Waived for accounts aged greater than one year from date of service.

The correct way to handle the retention and payment of agency fees is: - SOLUTION A. The agency

provides an annual settlement of monies received by the health care provider and the agency. B. Compare estimated collection costs to actual costs incurred. C. Validate bank deposits weekly as funds are received from the agency. **D. Follow the contractual agreement between the agency and the provider as to how monies sent to the agency will be handled.

Patient relations include: - SOLUTION **A. The ability to sensitively deal with patients or individuals

while managing collection efficiency. B. Applying hard-core techniques to collect monies owed regardless of what the patient or individual states during the call. C. Ignoring all patient complaint calls. D. Referring all patient complaint calls to the healthcare provider.

Collection agency reports should be provided: - SOLUTION A. Whenever staff have the time to

generate them. B. Whenever an account is cancelled. **C. In at least two formats regarding accounts assigned on a routine basis. D. As needed to prove recovery rates.

Collection results are: - SOLUTION A. Always guaranteed by the collection agency.

**B. Accurately calculated to demonstrate the actual recovery percentage rate. C. Calculated using agency's private formula. D. Never reported except during contract negotiations.

Which option is NOT a HFMA best practice? - SOLUTION A. Coordinate the resolution of bad debt

accounts with a law firm B. Establish policies and ensure that they are followed NOT - C. Coordinate account resolution activities with business affiliates D. Report back to credit bureaus when an account is resolved True or False: The following statement represents an advantage of outsourcing:

Access to qualified staff - SOLUTION **True

False True or False: The following statement represents an advantage of outsourcing:

Vendor absorbs some financial risk based on "efficiency" factor - SOLUTION **True

False True or False: The following statement represents an advantage of outsourcing:

Impact on direct control of accounts receivable - SOLUTION True

**False True or False: The following statement represents an advantage of outsourcing:

Capitalizes on the economies of scale - SOLUTION **True

False

True or False: The following statement represents an advantage of outsourcing:

Limits internal staffing requirements - SOLUTION **True

False True or False: The following statement represents an advantage of outsourcing:

Impact on customer service - SOLUTION True

**False True or False: The following statement represents an advantage of outsourcing:

Legal impact if vendor represents themselves as provider employees - SOLUTION True

**False True or False: The following statement represents an advantage of outsourcing:

Ineffective vendor results in increased costs - SOLUTION True

**False ABC Hospital has experienced a 16% increase in new patients over the past 6 months. The hospital is understaffed in its insurance claim and payment processing department and cannot handle this increase in work load. It is considering hiring an outsourcing vendor to assist. What are the steps that the

hospital needs to take to establish and ensure a successful vendor relationship? - SOLUTION **A.

Distribute a RFP to solicit vendor capabilities, evaluate vendor's expertise to provide outsourcing services, visit vendor locations, perform vendor reference checks, talk with vendor clients, interview vendor employees to assess experience level.

B. Evaluate vendor's expertise in providing outsourcing services, visit vendor locations, interview vendor employees to assess expertise level.

Which function within the revenue cycle is NOT a good candidate for outsourcing? - SOLUTION **A.

Health Care Patient Services B. Patient Accounting C. Patient Access D. Health Information Management Which of the following statements are true of HFMA's Financial Communications Best Practices -

SOLUTION The best practices were developed specifically to help patients understand the cost of

services, their individual insurance benefits, and their responsibility for balances after insurance, if any.

The patient experience includes all of the following except: - SOLUTION The average number of

positive mentions received by the health system or practice and the public comments refuting unfriendly posts on social media sites. Corporate compliance programs play an important role in protecting the integrity of operations and

ensuring compliance with federal and state requirements. The code of conduct is: - SOLUTION All of

the above Specific to Medicare fee-for-service patients, which of the following payers have always been liable for

payment? - SOLUTION Public health service programs, Federal grant programs, veteran affairs

programs, black lung program services and work-related injuries and accidents (worker' compensation claims) Provider policies and procedures should be in place to reduce the risk of ethics violations. Examples of

ethics violations include: - SOLUTION All of the above

Providers are now being reimbursed with a focus on the value of the services provided, rather than volume, which requires collaboration among providers. What is the intended outcome of collaborations made through an ACO delivery system for a

population of patients? - SOLUTION To eliminate duplicate services, prevent medical errors and

ensure appropriateness of care. Historically, revenue cycle has delt with contractual adjustments, bad debt and charity deductions from gross revenue. Although deductions continue to exist, the definition of net revenue has been modified through the implementation of ASC 606. Developed by the Financial Accounting Standards Board (FASB), this change became effective in 2018.

What is the new terminology now employed in the calculation of net patient services revenues? -

SOLUTION Explicit prices concessions and implicit price concessions

Key performance indicators set standards for A/R and provide a method for measuring the control and collection of A/R. What are the two KPIs used to monitor performance related to the production and submission of

claims to third party payers and patients (self-pay)? - SOLUTION Elapsed days from discharge to final

bill and elapsed days from final bill to claim/bill submission.

Consents are signed as part of the post-services process. - SOLUTION True

**False

Patient service costs are calculated in the pre-service process for schedule patients - SOLUTION

**True False

The patient is scheduled and registered for service is a time-of-service activity - SOLUTION True

**False

The patient account is monitored for payment is a time-of-service activity - SOLUTION True

**False

Case management and discharge planning services are a post-service activty - SOLUTION True

**False