Healthcare Revenue Cycle Management, Exams of Nursing

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CRCR Certification Exam Latest Update 2024/2025 5 Exam Sets Combined Complete Solution Package Overall aggregate payments made to a hospice are subject to a computed "cap amount" calculated by - correct answer The Medicare Administrative Contractor (MAC) at the end of the hospice cap period Which of the following is required for participation in Medicaid - correct answer Meet Income and Assets Requirements In choosing a setting for patient financial discussions, organizations should first and foremost - correct answer Respect the patients privacy A nightly room charge will be incorrect if the patient's - correct answer Transfer from ICU (intensive care unit) to the Medical/Surgical floor is not reflected in the registration system The Affordable Care Act legislated the development of Health Insurance Exchanges, where individuals and small businesses can - correct answer Purchase qualified health benefit plans regardless of insured's health status A portion of the accounts receivable inventory which has NOT qualified for billing includes: - correct answer Charitable pledges Medicare has established guidelines called the Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) that establish - correct answer What services or healthcare items are covered under Medicare 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 - correct answer The Provider Reimbursement Review Board Concurrent review and discharge planning - correct answer Occurs during service Duplicate payments occur: - correct answer When providers re-bill claims based on nonpayment from the initial bill submission 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 - correct answer A beneficiary appeal Insurance verification results in which of the following - correct answer The accurate identification of the patient's eligibility and benefits The Medicare fee-for service appeal process for both beneficiaries and providers includes all of the following levels EXCEPT: - correct answer Judicial review by a federal district court Under EMTALA (Emergency Medical Treatment and Labor Act) regulations, the providermay not ask about a patient's insurance information if it would delay what? - correct answer Medical screening and stabilizing treatment Ambulance services are billed directly to the health plan for - correct 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 Key performance indicators (KPIs) set standards for accounts receivables (A/R) and - correct answer Provide a method of measuring the collection and control of A/R he patient discharge process begins when - correct answer The physician writes the discharge orders The nightly room charge will be incorrect if the patient's - correct answer Transfer from ICU to the Medical/Surgical floor is not reflected in the registration system. The soft cost of a dissatisfied customer is - correct answer The customer passing on info about their negative experience to potential pts or through social media channels An advantage of a pre-registration program is - correct answer The opportunity to reduce the corporate compliance failures within the registration process It is important to have high registration quality standards because - correct answer Inaccurate or incomplete patient data will delay payment or cause denials Telemed seeks to improve a patient's health by - correct answer Permitting 2-way real time interactive communication between the patient and the clinical professional 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 - correct answer HMO Identifying the patient, in the MPI, creating the registration record, completing medical necessity screening, determining insurance eligibility and benefits resolving managed care, requirements and completing financial The two types of claims denial appeals are - correct answer Beneficiary and Provider Which of the following is a violation of the EMTALA (Emergency Medical Treatment and Labor Act?) - correct answer Registration staff members routinely contact managed care plans for prior authorizations before the patient is seen by the on duty physician Rural Health Clinics (RHC) personnel can provide services in all of the following locations, EXCEPT - correct answer Providing inpatient services in the RHC The patient discharge process begins when - correct answer The physician writes the discharge order Departments that need to be included in charge master maintenance include all of the following EXCEPT - correct answer Quality Assurance The first thing a health plan does when processing a claim is - correct answer Check if the patient is a health plan beneficiary and what is the coverage Vital to accurate calculations of a patient's self-pay amount is - correct answer The most accurate way to validate patient information is to - correct answer require clinical staff to verify information at each treatment encounter In order for Regulation Z to apply, a hospital must - correct answer All of the following are minimum requirements for new patients with no MPI number EXCEPT - correct answer Address A typical routine patient financial discussion would include - correct answer Explaining the benefits identified through verifying the patients insurance Components of financial education include informing the patient of the hospital's financial policies, assessing the patient's ability to pay and - correct answer Reviewing payment alternatives with the patient so appropriate resolution of the health care financial obligation is achieved HFMA best practices indicate that the technology evaluation is conducted to - correct answer Continually align technology with processes rather than technology dictating processes Scheduler instructions are used to prompt the scheduler to - correct answer Complete the scheduling process correctly based on service requested When billing Rural Health Clinic services on a UB-04/837-I, specific CPT codes are collapsed into a single revenue code (520 or 521). Although codes are collapsed into a single revenue code, it is still important to list the appropriate CPT codes as part - correct answer These codes will be used to determine medical necessity and useful in determining what happened during the encounter What is likely to occur if credit balances are not identified separately from debit balances in accounts receivable? - correct answer The accounts receivable level would be understated The process of verifying health insurance coverage, identifying contract terms, and obtaining total charges is known as - correct answer insurance verification and reimbursable charges Unless the patient encounter is an emergency, it is more efficient and effective to - correct answer Collect all information after the patient has been discharged Applying the contracted payment amount to the amount of total charges yields - correct answer A pricing agreement Revenue cycle activities occurring at the point-of-service include all of the following EXCEPT: - correct answer Providing charges to the third-party payer as they are incurred HFMA's patient financial communications best practices specify that pts should be told about the - correct answer The service providers that typically participate in the service, e.g. radiologists ,pathologists, etc. The core financial activities resolved within patient access include: - correct answer Scheduling, pre-registration, insurance verification and managed care processing A decision on whether a patient should be admitted as an inpatient or become about patient observation patient requires medical judgments based on all of the following EXCEPT - correct answer The patient's home care coverage Which option is a benefit of pre-registering a patient for services - correct answer The patient arrival process is expedited, reducing wait times and delays Days in A/R is calculated based on the value of - correct answer The total accounts receivable on a specific date Case Management requires that a case manager be assigned - correct answer To a select patient group Which of the following is required for participation in Medicaid? - correct answer Meet income and assets requirements All of the following are steps in safeguarding collections EXCEPT - correct answer Issuing receipts The Electronic Remittance Advice (ERA) data set is : - correct answer A standardized form that provides third party payment details to providers All of the following are conditions that disqualify a procedure or service from being paid for by Medicare EXCEPT - correct answer Services and procedures that are custodial in nature Medicare beneficiaries remain in the same "benefit period" - correct answer Until the beneficiary is "hospitalization and/or skilled nursing facility-free" for 60 consecutive days It is important to calculate reserves to ensure - correct answer Stable financial operations and accurate financial reporting A claim is denied for the following reasons, EXCEPT: - correct answer The submitted claim does not have the physicians signature HFMA best practices call for patient financial discussions to be reinforced - correct answer By changing policies to programs Patients should be informed that costs presented in a price estimate may - correct answer Vary from estimates, depending on the actual services performed The nuanced data resulting from detailed ICD-10 coding allows senior leadership to work with physicians to do all of the following EXCEPT: - correct answer Obtain higher compensation for physicians Charges as the most appropriate measurement of utilization enables - correct answer Accuracy of expense and cost capture Once the EMTALA requirements are satisfied - correct answer The remaining registration processing is initiated at the bedside or in a registration area A comprehensive "Compliance Program" is defined as - correct answer Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met An originating site is - correct answer The location of the patient at the time the service is provided Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) are Medicare established guideline(s) used to determine: - correct answer Which diagnoses, signs, or symptoms are reimbursable 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 - correct answer Will be admitted as an inpatient The benefit of Medicare Advantage Plan is - correct answer Patients generally have their Medicare-coverage healthcare through the plan and do not need to worry about "part a" or "part b" benefits The process of creating the pre-registration record ensures - correct answer Accurate billing Claims with dates of service received later than one calendar year beyond the date of service, will be - correct answer Denied by Medicare A portion of the accounts receivable inventory which has NOT qualified for billing includes - correct answer Charitable pledges The standard claim form used for billing by hospitals, nursing facilities, and other in-patient - correct answer UB-04 Once the price is estimated in the pre-service stage, a provider's financial best practice is to - correct answer Explain to the patient their financial responsibility and to determine the plan for payment Internal controls addressing coding and reimbursement changes are put in place to guard against - correct answer Compliance fraud by upcoding Health Plan Contracting Departments do all of the following EXCEPT - correct answer Establish a global reimbursement rate to use with all third-party payer For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions: - correct answer Should take place between the patient or guarantor and properly trained provider representatives What type of account adjustment results from the patient's unwillingness to pay a self-pay balance? - correct answer Bad debt adjustment Most major health plans including Medicare and Medicaid, offer - correct answer Electronic and/or web portal verification The important Message from Medicare provides beneficiaries information concerning their - correct answer Right to appeal a discharge decision if the patient disagrees with the plan 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? - correct answer Medical screening and stabilizing treatment Before classifying and subsequently writing off an account to financial assistance or bad debt, the hospital must establish policy, define appropriate criteria, implement - correct answer Monitor compliance The importance of medical records being maintained by HIM is that the patient records - correct answer Are the primary source for clinical data required for reimbursement by health plans and liability payers Days in A/R is calculated based on the value of: - correct answer The time it takes to collect anticipated revenue To maximize the value derived from customer complaints, all consumer complaints should be - correct answer Responded to within two business days A scheduled inpatient represents an opportunity for the provider to do which of the following? - correct answer Complete registration and insurance approval before service In the pre-service stage, the requested service is screened for medical necessity, health - correct answer Pre-authorization are obtained Hospitals need which of the following information sets to assess a patient's financial status: - correct answer Patient and guarantor's income, expenses and assets Patients are contacting hospitals to proactively inquire about costs and fees prior to - correct answer The fact that charge master lists the total charge, not net charges that reflect charges after a payer's contractual adjustment HIPAA had adopted Employer Identification Numbers (EIN) to be used in standard transactions to identify the employer of an individual described in a transaction EIN's are assigned by - correct answer The Internal Revenue Service The HCAHPS (hospital consumer assessment of healthcare providers and systems) initiative - correct answer Provide a standardized method for evaluating patient's perspective on hospital care. A large number of credit balances are not the result of overpayments but of - correct answer Posting errors in the patient accounting system A Medicare Part A benefit period begins: - correct answer With admission as an inpatient Chapter 13 Bankruptcy, debtor rehabilitation, is a court proceeding - correct answer That reorganizes a debtor's holdings and instructs creditors to look to the debtor's future earnings for payment Which of the following in NOT included in the Standardized Quality Measures - correct answer Cost of services The disadvantages of outsourcing include all of the following EXCEPT: - correct answer Reduced internal staffing costs and a reliance on outsourced staff Improving the overall patient experience requires revenue cycle leadership and staff to simultaneously be: - correct answer Clear on policies and consistent in applying the policies Because 501(r) regulations focus on identifying potential eligible financial assistants patients hospitals must: - correct answer Hold financial conversations with patients as soon as possible Which of the following is NOT contained in a collection agency agreement? - correct answer A mutual hold-harmless clause HFMA best practices stipulate that a reasonable attempt should be made to have the financial - correct answer As early as possible, before a financial obligation is incurred A four digit number code established by the National Uniform Billing Committee (NUBC)that categorizes/classifies a line item in the charge master is known as - correct answer Revenue codes Appropriate training for patient financial counseling staff must cover all of the following EXCEPT: - correct answer Documenting the conversation in the medical records The ACO investment model will test the use of pre-paid shared savings to - correct answer Encourage new ACOs to form in rural and underserved areas When recovery audit contractors (RAC) identify improper payments as over payments the claims processing contractor must - correct answer Send a demand letter to the provider to recover the over payment amount The purpose of the ACA mandated Community Health Needs Assessment is - correct answer To identify significant health needs, prioritize those needs and identify resources to address them A balance sheet is - correct answer A statement of assets, liabilities, and capital for an organization at a specified point in time Hospitals can only convert an inpatient case to observation if the hospital utilization review committee determines this status before the patient is discharged and - correct answer Prior to billing, that an observation setting will be more appropriate During pre-registration, a search for the patients MPI number is initiated using which of the following data sets? - correct answer Patient's full legal name and date of birth or the patient's Social Security number Because case managers document the clinical reasons for treatment, they are - correct answer A good resource when developing written appeals of denials The Truth in Lending Act establishes - correct answer Disclosure rules for consumer credit sales and consumer loans What is Continuum of Care? - correct answer The coordination and linkage of resources needed to avoid the duplication of services and the facilitation of a seamless movement among care settings HIPAA privacy rules require covered entities to take all of the following actions EXCEPT - correct answer Use only designated software platforms to secure patient data The Two Midnight Rule allows hospitals to account for total hospital time when determining if an inpatient admission order should be written based on - correct answer A beneficiary needing a minimum of 48 hours of care Since passage 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 - correct answer Assist patients in understanding their insurance coverage and their financial obligation HFMA patient financial communications best practices call for annual training for all staff EXCEPT - correct answer Nursing The process of verifying health insurance coverage, identifying contract terms, and obtaining total charges is known as - correct answer Insurance verification of reimbursable charges Net Accounts Receivable is - correct answer The amount an entity is reasonably confident of collecting from overall accounts receivable. ED patients should be informed that their ability to pay - correct answer Will not interfere with treatment of any emergency medical conditions The result of accurate census balancing on a daily basis is - correct answer The correct recording of room charges All of the following are steps in verifying insurance EXCEPT - correct answer The patient signing the statement of financial responsibility Health Information Management (HIM) is responsible for - correct answer All patient medical records This form contains major items, subdivided into a total of 55 detailed items, and is used by professional service providers and not hospitals for submitting claims for services to health plans this form is called - correct answer The 1500 Which of the following is NOT a factor in self-pay follow-up? - correct answer The type of patient (inpatient, out-patient) The Office of Inspector General (OIG) was created - correct answer Detect and prevent fraud, waste, and abuse - correct answer CRCR Exam Prep Questions With Verified Answers Graded A+ (2024/2025) 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 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 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 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 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 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 Certified Revenue Cycle Representative - CRCR (2024/2025) Questions and Answers Which of the following statements are true of HFMA's Financial Communications Best Practices - correct answer 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: - correct answer 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: - correct answer All of the above Specific to Medicare fee-for-service patients, which of the following payers have always been liable for payment? - correct answer 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: - correct answer 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. Which option is NOT a main HFMA Healthcare Dollars & Sense® revenue cycle initiative? - correct answer A. Patient Financial Communications B. Price Transparency C. Medical Account Resolution **D. Process Compliance What is the objective of the HCAHPS initiative? - correct answer **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? - correct answer A. Information Technology B. Clinical Services C. Finance **D. Assisted Living Services Which option is NOT a continuum of care provider? - correct answer A. Physician **B. Health Plan Contracting C. Hospice D. Skilled Nursing Facility Which of the following are essential elements of an effective compliance program? - correct answer **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. - correct answer 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? - correct answer **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: - correct answer 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? - correct answer **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? - correct answer **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: - correct answer 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. **B. Medicaid C. Self-Insured Plans D. Liability Coverage Which option is NOT a specific managed care requirement? - correct answer A. Referrals B. Notification **C. Preferred Provider Organization D. Discharge Planning What is the first component of a pricing determination? - correct answer 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: - correct answer 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? - correct answer 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? - correct answer ALL of the above Typical activities which much be performed when an unscheduled patient arrives for service include: - correct answer 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: - correct answer 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: - correct answer 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: - correct answer 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: - correct answer 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: - correct answer 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: - correct answer 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: - correct answer 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: - correct answer Payers will waive timely filing denials for claims filed over a year from date of service. What does EMTALA require hospitals to do? - correct answer **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? - correct answer A. By reviewing a patient's individual case and recommend treatment changes. Credit balances may be created by any of the following activities except: - correct answer Credits to pharmacy charges posted before the claim final bills Which of the following statements represent common reasons for inpatient claim denials? - correct answer 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? - correct answer 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: - correct answer 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: - correct answer 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)3 providers, the hospital must complete which of the following activities: - correct answer A community needs assessmenets The three types of bankruptcy as defined in the 1979 Bankruptcy Act are: - correct answer 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: - correct answer 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? - correct answer 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? - correct answer 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: - correct answer 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? - correct answer **A. Manually match the ERA to the patient account. B. Nothing unless there is an error. What is EFT? - correct answer **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? - correct answer 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? - correct answer A. Technical B. Clinical C. Underpayment **D. Contractual Adjustment Which option is NOT a lien type? - correct answer 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? - correct answer 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? - correct answer A. Eligibility criteria B. Application process C. Application assistance Vendor absorbs some financial risk based on "efficiency" factor - correct answer **True False True or False: The following statement represents an advantage of outsourcing: Impact on direct control of accounts receivable - correct answer True **False True or False: The following statement represents an advantage of outsourcing: Capitalizes on the economies of scale - correct answer **True False True or False: The following statement represents an advantage of outsourcing: Limits internal staffing requirements - correct answer **True False True or False: The following statement represents an advantage of outsourcing: Impact on customer service - correct answer True **False True or False: The following statement represents an advantage of outsourcing: Legal impact if vendor represents themselves as provider employees - correct answer True **False True or False: The following statement represents an advantage of outsourcing: Ineffective vendor results in increased costs - correct answer 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? - correct answer **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? - correct answer **A. Health Care Patient Services B. Patient Accounting C. Patient Access D. Health Information Management CRCR STUDY QUESTIONS AND ANSWERS (RATED A+) 2024/2025 code of conduct - correct answer hospital establish compliance standards Purpose of OIG work plan? - correct answer communicate issues that will be reviewed during the year for compliance with Medicare regulations Medicare pt. admitted on Friday, what services fall within the three day window rule? - correct answer Dx services and related charges provided on the W,R, and F before adm. what document must a primary care phys. send to an HMO pt. to authorize a visit to a specialist for add. testing or care? - correct answer referral activities are completed when a scheduled, pre reg pt. arrives for service? - correct answer activating the record, obtaining signatures, and finalizing financial issues under EMTALA reg., the provider may not ask about a pts. ins. info if it would delay what - correct answer medical screening and stabilizing treatment collecting pt liability dollars after service leads to what - correct answer increased efforts by pt acct staff to resolve these balanaces important message from medicare provides beneficiaries with info concerning what? - correct answer right to appeal a discharge decision if the pt disagrees with the plan which of the following is a step in the discharge process? - correct answer have case management services complete the discharge plan what curcumstances would result in an incorrect nightly room charge? - correct answer if pt. transfer from the ICU to medical/surgical floor is not reflected in the reg system which stmnt describes the goal of fin counseling services - correct answer help the pt. understand insurance coverage, including what the pt will owe for the current services hospital has an APC based contract for the payment of out pt. services. total anticipated charges for the visit are 2,380. the approved apc payment rate is 780. Where will the patient benefit package be applied? - correct answer to the approved APC payment rate pt. has met the 200 ind. deductible and 900 of the 1000 co-ins. resp. the co-ins. rate is 20%. the est. ins. plan respon is 1975. what amt. of co-ins. is due from pt. - correct answer 100 which of the following items are considered valid proof of income documents. - correct answer copies of paycheck stubs from the recent three months When is a pt. considered to be medically indigent? - correct answer pt. outstanding med bills exceed a defined dollar amt or percent of asset what pt assets are considered in the fin assist app - correct answer primary residence if the pt cannot agree to payment arrangments, what is the next best option - correct answer warn pt that unpaid accts are placed w collection agencies for further processing what are numbered receipts for - correct answer ensure all payments are properly acted for and deposited what is an effective tool to help staff collect payments at time of service - correct answer develop scripts for the process of requesting payment what must happen to cash, checks, and credit card transactions at the end of each shift - correct answer balance why is it important to have a high quality standards for reg. - correct answer bc quality failures affect the providers Joint Commish results on review day how does utilization review staff use correct ins info - correct answer obtain approval for in pt. days and coordinate services what core fin activities are resolved within pt. access - correct answer scheduling, pre-reg, ins verif, mng care process what is an unscheduled direct admission - correct answer pt. who is admitted from the physicians office on an urgent basis when is not appro to use an observ status - correct answer as a sub for in pt admission pt who require periodic skilled nursing or therapeutic care receive services from what type of program - correct answer home health agency type of info that is typically collected during the scheduling contact - correct answer pt name, dob, sex, dx, req test/proced, prefer dos, ordering phys, pt tele # every pt who is new to health care provider must be offered what - correct answer printed copy f providers privacy notice which stmnt applies to self insured plans - correct answer employer assumes direct respon and risk for employee healthcare claims info recorded in a 270 transaction - correct answer dob process that pt health plan uses to retroact collect payments from liability, auto, or wc - correct answer subrogation why do mnged care plans have agreements w/ hospitals physiciansm and other healthcare providers to offer a range of services to plan members - correct answer reduce healthcare costs in what type of pymnt method is lump sum or bndled payment negotiated between payer and some/all providers - correct answer packaged pricing 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 limitations what does scheduling allow a provider staff to do - correct answer review the approp of the service requested when an adult pt is covered by both his own and his spouses health ins plan, which of the stmnt is true - correct answer pt ins is the primary ins. claim is related to an accident, what must the hospital report - correct answer county in which the accident occured mrs jones, a med beneficiary, was admitted to the hospital on june 20, 2010. as of the admission date, she had only used 8 in pt. days in the current benefit period. if not discharged, on what date will mrs. jones exhaust her full coverage days - correct answer August 9, 2010 in order to meet eligibility guidlelines for healthcare beneifts, Medicaid beneficiaries must fall into a specified need category and meet what other type of requirment - correct answer income and expense most managed care plans do not permit pt balances billing except for what cirumstances - correct answer deductible and copayments requirements fee for service plans pay claims based on a percentage of charges. how are pt out of pocket costs calculated? - correct answer limited be federal ERISA statues MSP rules allow providers to bill medicare for liability claims after what happens - correct answer 120 days pass, but claim must be withdrawn from liability carrier what form is used to bill medicare - correct answer ub-04 two statutory exclusions from hospice coverage - correct answer medically unnecessary services and custodial care examples of hospital-based physicians - correct answer ED physicans, radiologist, and pathologists advantage of provider based clinic - correct answer ability to bill both the technical component and the professional component by the provider example of a technical denial - correct answer exceeding frequency limitations how does financial counseling process begin - correct answer explain the hospitals credit and collection policies and what they mean to the patients hoe does a health pln recover dollars paid for a liability claim from the liability carrier - correct answer subrogation type of acct adjustment results from the pt inability to pay a self balance - correct answer charity adjustment according to the department of health and human services guidelines, which of the following is not considered income - correct answer sale of property , house, or car what must a provider do to qualify an acct as a medicare bad debt - correct answer pursue the acct for 120 days and then refer it to an outside collection agency revenue cycle begins with scheduling a pt. for service and ends with what - correct answer archiving of the fully resolved acct how does increasing the provision for bad debts affect the financial statements - correct answer reduces gross receivables and increase operating expense for the period a successful medicare pay for performance initiative will likely result iin what - correct answer higher payments while covering sicker beneficiaries what are some component of the charge master - correct answer room charges and detailed ancillary charges using pt specific info, calculate the pt liability for MRI of the right knww. the charge master price based on CPT code for MRI is 2500; the payers contract discount wtht the provider is 20% of the charges; the pt benefit plan deductible of 80/20 with no limit on pt portion was met - correct answer 400 how are charges recorded as charity care treated - correct answer as a deduction from the revenue that is reported as a footnote to the financial statments what type of utilization review are used to ensure that resources and services are provided in the most efficient and effective ways - correct answer prospective review, concurrent review, and retrospective review the situation where neither the pt nor spouse is employed is described to the payer using: - correct answer a condition code regulations and requirements for creating accountable care organizations which allowed providers to beign creating these organization were finalized - correct answer 2012 what is correct discharge status code for a pt who is discharged to a swing bed unit in the same hospital - correct answer 61 what is the primary responsibility of the recovery audit contractor - correct answer to correct identity proper payments for medicare part a and b claims The account resolution clock begins when - correct answer The first statement is sent to the patient The soft cost of a dissatisfied customer is - correct answer The customer passing on information about their negative experience to potential patients or through social media channels The hard cost of a dissatisfied customer is - correct answer loss of future revenue When there is a request for service, scheduling staff must first - correct answer Confirm the patients key identification information A standardized form informing patients about the conditions that must be agreed to as part of the agreement for the hospital to provide care is called - correct answer Conditions of admission Hospitals need which of the following information sets to assess a patients financial status - correct answer Demographic, Income, Assets, and Expenses For new patients with no MPI number - correct answer A new medical record will be created by the provider Which option is a government sponsored program that is financed through taxes and general revenue funds - correct answer Medicare An increase in the dollars aged greater than 90 days from date of service indicates that accounts are - correct answer Not resolved in a timely manner In many states, people covered under the Medicaid program are required to join managed care plans focusing on preventive healthcare - correct answer Medicaid Advantage Price is defined as; - correct answer The amount actually paid by the health plan and/or the patient for a specific service 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; - correct answer The fact that chargemaster lists the total charge, not net charges that reflect charges after a payer's contractual adjustment 19) Time of the patient portion earlier in the cycle and increases patient satisfaction because; - correct answer There is clarity for the patient about what is owed. Because case managers are well positioned to document the clinical reasons for treatment, they are; - correct answer Of great assistance to revenue cycle staff working on written appeals for denials 21) The best practice in billing is to generate bills and financial information that is: - correct answer Clear, concise, correct, and patient-friendly. 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; - correct answer Identify, compare, and choose providers that offer the desired level or value. The 501 (r) regulations require not-for-profit providers 501 (c)(3) to do which of the following activities: - correct answer Implement a financial assistance program for uninsured and underinsured patients. Net Accounts Receivable is - correct answer The amount an entity is reasonably confident of collecting from overall accounts receivable The revenue cycle includes - correct answer All of the major processing steps required to process a patient account from the request for service through closing the account 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 - correct answer Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow Medicare patients are NOT required to produce a physicians order to receive which of these services - correct answer Screening mammograms', flu vaccine or pneumonia For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions: - correct answer Should take place between the patient or guarantor and properly trained provider representatives. For non-routine scenarios, such as uninsured or underinsured patients: - correct answer A financial counselor or supervisor should be involved. The Two Midnight Rule allows hospitals to account for total Hospital time Including - correct answer Outpatient time directly preceding the inpatient admission The purpose of the ACA mandated Community Health Needs Assessment is; - correct answer To identify significant health needs, prioritize those needs and identify resources to address them. Unless the patient encounter is an emergency, it is more efficient and effective to; - correct answer Obtain the required demographic and insurance information before services are rendered. What is likely to occur if credit balances are not identified separately from debit balances in accounts receivable? - correct answer The accounts receivable level would be understated.