Healthcare Revenue Cycle Terminology and Concepts, Exams of Topography

Download Healthcare Revenue Cycle Terminology and Concepts and more Exams Topography in PDF only on Docsity!

CRCR Exam Prep questions and answers

latest top score.

What are collection agency fees based on? - correct answer. A percentage of dollars collected

Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - correct answer. Birthday

In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - correct answer. Case rates

What customer service improvements might improve the patient accounts department?

• correct answer. Holding staff accountable for customer service during performance reviews

What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - correct answer. Inform a Medicare beneficiary that Medicare may not pay for the order or service

What type of account adjustment results from the patient's unwillingness to pay for a self-pay balance? - correct answer. Bad debt adjustment

What is the initial hospice benefit? - correct answer. Two 90-day periods and an unlimited number of subsequent periods

When does a hospital add ambulance charges to the Medicare inpatient claim? - correct answer. If the patient requires ambulance transportation to a skilled nursing facility

How should a provider resolve a late-charge credit posted after an account is billed? - correct answer. Post a late-charge adjustment to the account

an increase in the dollars aged greater than 90 days from date of service indicate what about accounts - correct answer. They are not being processed in a timely manner

What is an advantage of a preregistration program? - correct answer. It reduces processing times at the time of service

What are the two statutory exclusions from hospice coverage? - correct answer. Medically unnecessary services and custodial care

What core financial activities are resolved within patient access? - correct answer. Scheduling, insurance verification, discharge processing, and payment of point-of- service receipts

What statement applies to the scheduled outpatient? - correct answer. The services do not involve an overnight stay

How is a mis-posted contractual allowance resolved? - correct answer. Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount

What type of patient status is used to evaluate the patient's need for inpatient care? - correct answer. Observation

Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - correct answer. Medically necessary inpatient hospital services for at least 3 consecutive days before the skilled nursing care admission

When is the word "SAME" entered on the CMS 1500 billing form in Field 0$? - correct answer. When the patient is the insured

What are non-emergency patients who come for service without prior notification to the provider called? - correct answer. Unscheduled patients

If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - correct answer. Neither enrolled not entitled to benefits

Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what? - correct answer. Disclosure rules for consumer credit sales and consumer loans

What is a principal diagnosis? - correct answer. Primary reason for the patient's admission

Collecting patient liability dollars after service leads to what? - correct answer. Lower accounts receivable levels

What is the daily out-of-pocket amount for each lifetime reserve day used? - correct answer. 50% of the current deductible amount

What service provided to a Medicare beneficiary in a rural health clinic (RHC) is not billable as an RHC services? - correct answer. Inpatient care

What code indicates the disposition of the patient at the conclusion of service? - correct answer. Patient discharge status code

What are hospitals required to do for Medicare credit balance accounts? - correct answer. They result in lost reimbursement and additional cost to collect

When an undue delay of payment results from a dispute between the patient and the third party payer, who is responsible for payment? - correct answer. Patient

Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: - correct answer. A valid CPT or HCPCS code

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

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

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

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

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

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

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

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

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

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

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

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

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

What type of provider bills third-party payers using CMS 1500 form - correct answer. Hospital-based mammography centers

How are disputes with nongovernmental payers resolved? - correct answer. Appeal conditions specified in the individual payer's contract

The important message from Medicare provides beneficiaries with information concerning what? - correct answer. Right to appeal a discharge decision if the patient disagrees with the services

Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - correct answer. To improve access to quality healthcare

If a patient remains an inpatient of an SNF (skilled nursing facility for more than 30 days, what is the SNF permitted to do? - correct answer. Submit interim bills to the Medicare program.

90. MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - correct answer. 120 days passes, but the claim then be withdrawn from the liability carrier

What data are required to establish a new MPI entry? - correct answer. The patient's full legal name, date of birth, and sex

What should the provider do if both of the patient's insurance plans pay as primary? - correct answer. Determine the correct payer and notify the incorrect payer of the processing error

What do EMTALA regulations require on-call physicians to do? - correct answer. Personally appear in the emergency department and attend to the patient within a reasonable time

At the end of each shift, what must happen to cash, checks, and credit card transaction documents? - correct answer. They must be balanced

What will cause a CMS 1500 claim to be rejected? - correct answer. The provider is billing with a future date of service

Under Medicare regulations, which of the following is not included on a valid physician's order for services? - correct answer. The cost of the test

how are HCPCS codes and the appropriate modifiers used? - correct answer. To report the level 1, 2, or 3 code that correctly describes the service provided

If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - correct answer. Diagnostic and clinically-related non-diagnostic charges provided on the Tuesday, Wednesday, Thursday, and Friday before admission

What is a benefit of pre-registering patient's for service? - correct answer. Patient arrival processing is expedited, reducing wait times and delays

What is a characteristic of a managed contracting methodology? - correct answer. Prospectively set rates for inpatient and outpatient services

What do the MSP disability rules require? - correct answer. That the patient's spouse's employer must have less than 20 employees in the group health plan

what organization originated the concept of insuring prepaid health care services? - correct answer. Blue Cross and blue Shield

What is true about screening a beneficiary for possible MSP situations? - correct answer. It is acceptable to complete the screening form after the patient has completed the registration process and been sent to the service department

If the patient cannot agree to payment arrangements, what is the next option? - correct answer. Warn the patient that unpaid accounts are placed with collection agencies for further processing

In services lines such as cardiology or orthopedics, what does the case-rate payment methodology allow providers to do? - correct answer. Receive a fixed for specific procedures

What will comprehensive patient access processing accomplish? - correct answer. Minimize the need for follow-up on insurance accounts

Through what document does a hospital establish compliance standards? - correct answer. Code of conduct

How does utilization review staff use correct insurance information? - correct answer. To obtain approval for inpatient days and coordinate services

When is it not appropriate to use observation status? - correct answer. As a substitute for an inpatient admission

What is a serious consequence of misidentifying a patient in the MPI? - correct answer. The services will be documented in the wrong record

When a patient reports directly to a clinical department for service, what will the clinical department staff do? - correct answer. Redirect the patient to the patient access department for registration

What process can be used to shorten claim turnaround time? - correct answer. Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail

How are patient reminder calls used? - correct answer. To make sure the patient follows the prep instructions and arrives at the scheduled time for service

If a patient declares a straight bankruptcy, what must the provider do? - correct answer. Write off the account to the contractual adjustment account

According to the Department of Health and Human Services guidelines, what is NOT considered income? - correct answer. Sale of property, house, or car

The situation where neither the patient nor spouse is employed is described to the patient using: - correct answer. A condition code

What option is an alternative to valid long-term payment plans? - correct answer. Bank loans

What is an advantage of using a collection agency to collect delinquent patient accounts? - correct answer. Collection agencies collect accounts faster than hospital does

What statement DOES NOT apply to revenue codes? - correct answer. revenue codes identify the payer

When a patient's illness results in an unusually high amount of medical bills not covered by insurance or other patient pay resources, what type of account is created - correct answer. catastrophic charity

What happens when a patient receives non-emergent services from and out-of-network provider? - correct answer. Patient payment responsibility is higher

Every patient who is new to the healthcare provider must be offered what? - correct answer. A printed copy of the provider's privacy notice

How may a collection agency demonstrate its performance? - correct answer. Calculate the rate of recovery

What is true of the information the provider supplies to indicate that an authorization for service has been received from the patient's primary payer? - correct answer. It is posted on the remittance advice by the payer

What standard claim forms are currently used by the healthcare industry to submit claims to third-party payers? - correct answer. The UB-04 and the CMS 1500

Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information? - correct answer. Obtain the required demographic and insurance information before services are rendered

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

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

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

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

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

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

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

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

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

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

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

What is an effective tool to help staff collect payments at the time of service? - correct answer. Develop scripts for the process of requesting payments

What is a benefit of electronic claims processing? - correct answer. Providers can electronically view patient's eligibility

What does Medicare Part D provide coverage for? - correct answer. Prescription drugs

What are some core elements of a board-approved financial policy - correct answer. Charity care, payment methods, and installment payment guidelines

What circumstance would result in an incorrect nightly room charge? - correct answer. If the patient's discharge, ordered for tomorrow, has not been charted

What is NOT a typical charge master problem that can result in a denial? - correct answer. Does not include required modifiers

Access - correct answer. An individual's ability to obtain medical services on a timely and financially acceptable level

Administrative Services Only (ASO) - correct answer. Usually contracted administrative services to a self-insured health plan

Case management - correct answer. The process whereby all health-related components of a case are managed by a designated health professional. Intended to ensure continuity of healthcare accessibility and services

Claim - correct answer. A demand by an insured person for the benefits provided by the group contract

Coordination of benefits (COB) - correct answer. a typical insurance provision that determines the responsibility for primary payment when the patient is covered by more than one employer-sponsored health benefit program

Discounted fee-for-service - correct answer. A reimbursement methodology whereby a provider agrees to provide service on a fee for service basis, but the fees are discounted by certain packages

Eligibility - correct answer. Patient status regarding coverage for healthcare insurance benefits

First dollar coverage - correct answer. A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses

Gatekeeping - correct answer. A concept wherein the primary care physician provides all primary patient care and coordinates all diagnostic testing and specialty referrals required for a patient's medical care

Health plan - correct answer. an insurance company that provides for the delivery or payment of healthcare services

Indemnity insurance - correct answer. negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations

Medically necessary - correct answer. Healthcare services that are required to preserve or maintain a person's health status in accordance with medical practice standards

Out-of-area benefits - correct answer. healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO

Out-of-pocket payments - correct answer. Cash payments made by the insured for services not covered by the health insurance plan

Pre-admission review - correct answer. the practice of reviewing requests for inpatient admission before the patient is admitted to ensure that the admission is medically necesary

Pre-existing condition limitation - correct answer. A restriction on payments for charges directly resulting from a pre-existing health conditions

Same-day admission - correct answer. A cost containment practice that reduces a surgical patient's inpatient stay by requiring that pre-procedure testing and preparation are completed on an outpatient basis and the patient is admitted the same day as the procedure

Self-insured - correct answer. Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance

Subrogation - correct answer. Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses

Subscriber - correct answer. An employer, a union, or an association that contracts with an insurance company for the healthcare plan it offers to eligible employees

Sub-specialist - correct answer. A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery

Third-part administrator (TPA) - correct answer. Provides services to employers or insurance companies for utilization review, claims payment and benefit design

Third-party reimbursement - correct answer. A general term used for the healthcare benefit payments - used to identify that for benefit plans there are three parties in the transaction

Usual, customary, and reasonable (UCR) - correct answer. Health insurance plan reimbursement methodology that limits payment to the lower billed charges, the provider's customary charge, or the prevailing charge for the service in the community

Utilization review - correct answer. Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients

Charge - correct answer. The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid

Cost - correct answer. The definition of cost varies by party incurring the expense

Price - correct answer. the total amount a provider expects to be paid by payers and patients for healthcare services

Care purchaser - correct answer. Individual or entity that contributes to the purchase of healthcare services

Payer - correct answer. An organization that negotiates or sets rates for provider services, collects revenue through premium payments or tax dollars, processes provider claims for service, and pays provider claims using collected premium or tax revenues

Provider - correct answer. An entity, organization, or individual that furnishes a healthcare service

Out of pocket payment - correct answer. The portion of the total payment for medical services and treatment for which the patient is responsible, including copayments, coinsurance, and deductibles

Price transparency - correct answer. In health care, readily available information on the price of healthcare services that, together, with other information helps define the value of those services and enables patients and other care purchasers to identify, compare, and choose providers that offer the desired level of value

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

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

FERA - correct answer. Fraud Enforcement and Recovery act

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

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

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

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

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

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

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

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

What MSP situation requires LGHP - correct answer. Disability