Healthcare Revenue Management Final Exam, Exams of Nursing

Download Healthcare Revenue Management Final Exam and more Exams Nursing in PDF only on Docsity! Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ Abuse - CORRECT ANSWERS Unknowing or unintentional submission of an inaccurate claim for payment Accountable Care Organization (ACO) - CORRECT ANSWERS population- based model for healthcare delivery and payment Accounts Receivable (AR) - CORRECT ANSWERS The amounts owed to a facility by patients or insurance companies who receive services but whose payments will be made at a later date. Actual Charge - CORRECT ANSWERS The amount a physician or supplier actually bills for a particular service or supply. Adjudication - CORRECT ANSWERS (1) The determination of the reimbursement amount based on the beneficiary's insurance plan benefits. (2) The process by the payer of paying claims submitted or denying them after comparing the claim to the benefit and coverage requirements. Adjustment - CORRECT ANSWERS Allowable charge - CORRECT ANSWERS amount the third-party payer or insurance company will pay for a service Ambulatory Payment Classification (APC) - CORRECT ANSWERS A resource-based system used in the Medicare Hospital Outpatient Prospective Payment System (OPPS). The APC system combines procedures and services that are clinically comparable, with respect to resource use, into groups which are used to determine reimbursement levels. Ambulatory surgery center (ASC) - CORRECT ANSWERS Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, record keeping, and financial and accounting systems; has as its sole purpose the provision of services in connection Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation Appeal - CORRECT ANSWERS A request for a review of an insurance claim that has been underpaid or denied by an insurance company in an effort to receive additional payment. Assignment of benefits - CORRECT ANSWERS Contract between a physician and Medicare in which the physician agrees to bill Medicare directly for covered services, to bill the beneficiary only for any coinsurance or deductible that may be applicable and to accept the Medicare payment as a payment in full. Medicare usually pays 80% of the approved amount directly to the provider of services after the beneficiary meets the annual Part B deductible. The beneficiary pays the other 20% (coinsurance). Barcoding - CORRECT ANSWERS Tagging the packaging of each item with a machine-readable Universal Product Code (UPC) to identify a medication Benchmarking - CORRECT ANSWERS The process of comparing performance with a preestablished standard or performance of another facility or group. Beneficiary - CORRECT ANSWERS An individual who is eligible for benefits from a health plan Benefit Period - CORRECT ANSWERS Length of time that a health insurance policy will pay benefits for the member, family, and dependents. Birthday rule - CORRECT ANSWERS The method of determining primary coverage for a dependent child, under which the plan of the parent whose birthday occurs first in the calendar year is designated as primary. Bundling - CORRECT ANSWERS Occurs when payment for multiple significant procedures or multiple units of the same procedure related to an Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ reconciliation can be made via write-off or adjustment to the patient's account. Once the account has been settled, the revenue cycle is completed. Claim submission - CORRECT ANSWERS Billable fees are submitted to the insurance company via a universal claim for payment Clean claim - CORRECT ANSWERS A completed insurance claim form submitted with the program time limit that contains all the necessary information without deficiencies so it can be processed and paid promptly; a clean claim passes all electronic edits. Clearinghouse - CORRECT ANSWERS A vendor that processes healthcare claims for a healthcare organization CMS 1450 (8371) - CORRECT ANSWERS Facility. Institutional providers include: Community Mental Health Centers (CMHCs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), Critical Access Hospitals (CAHs), ESRD providers, Federally Qualified Health Centers (FQHCs), Histocompatibility laboratories, Home Health Agencies (HHAs), Hospice organizations, Hospitals, Indian Health Service (IHS) Facilities, Organ Procurement Organizations, Outpatient Physical Therapy (OPT)/ Occupational Therapy (OT)/Speech-Language Pathology (SLP) Services, Religious non-medical health care institutions (RNHCIs), Rural health clinics (RHCs), and Skilled nursing facilities (SNFs) CMS 1500 (837P) - CORRECT ANSWERS A standardized data set for the non-institutional or "professional" healthcare community for submission of claims. The "837P" refers to the way the claim is submitted electronically by EDI. CMS Hierarchical Condition Categories (CMS-HCC) - CORRECT ANSWERS Groups of related diagnoses for a patient based on the ICD-10-CM codes assigned. Coinsurance - CORRECT ANSWERS Cost sharing provision which is a preestablished percentage of eligible expenses to be paid by the beneficiary after the deductible has been met. Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ Comorbidity - CORRECT ANSWERS Pre-existing condition that, because of its presence with a specific diagnosis , causes an increase in length of stay by at least one day in approximately 75% of the cases (as in complication and comorbidity [CC]). Compliance - CORRECT ANSWERS 1. The process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or the healthcare organizations ethical and business policies. 2. The act of adhering to official requirements. 3. Managing a coding or billing department according to the laws, regulations, and guidelines that govern it. Complication - CORRECT ANSWERS (1) A medical condition that arises during an inpatient hospitalization (for example, a postoperative wound infection). (2) A condition that arises during the hospital stay that prolongs the length of stay at least by one day in approximately 75% of the cases (as in complication and comorbidity [CC]). Complications and comorbidities (CC) - CORRECT ANSWERS Diagnosis codes, that when reported as a secondary diagnosis have the potential to impact the MS-DRG assignment by increasing the MS-DRG up one level. CC codes represent an increase in resource intensity for the admission. Comprehensive Error Rate Testing (CERT) Program - CORRECT ANSWERS Measures improper payments for the Medicare fee for services payment systems as mandated by the Improper Payments Elimination and Recovery Improvement Act of 2012 Contractual allowance - CORRECT ANSWERS The difference between the actual charge and allowable charge. Contracted discount rate - CORRECT ANSWERS Reimbursement method in which the third-party payer has negotiated a reduced (discounted) fee for its covered insureds. Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ Conversion Factor (CF) - CORRECT ANSWERS national dollar multiplier that sets the allowance for the relative values; a constant Coordination of Benefits (COB) - CORRECT ANSWERS Method of integrating benefits payments from multiple healthcare insurers to ensure that payments do not exceed 100% of the covered healthcare expenses. Contract matrix - CORRECT ANSWERS Each healthcare provider or facility must manage a set of healthcare reimbursement contracts that specify how each claim will be reimbursed for the care provided by their clinical team. Copayment - CORRECT ANSWERS Cost-sharing measure in which the beneficiary pays a fixed dollar amount per service, supply, or procedure that is owed to the healthcare facility by the patient. Cost Sharing - CORRECT ANSWERS Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; a cost-control mechanism. Current Procedural Terminology (CPT) - CORRECT ANSWERS Coding system created and maintained by the American Medical Association that is used to report diagnostic and surgical services and procedures. Days in total discharge not final billed (DNFB) - CORRECT ANSWERS A measure of the efficiency of the claims generation process in the claims processing component of the revenue cycle. The number of days it takes to prepare a claim for TPP submission once the patient is discharged. Deductible - CORRECT ANSWERS Annual amount of money that the policyholder must incur (and pay) before the health insurance plan will assume liability for the remaining charges or covered expenses. Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ Fraud - CORRECT ANSWERS Healthcare provider requesting payment or reward when the requester knows it is against healthcare rules and regulations. Gatekeeper - CORRECT ANSWERS Healthcare provider or entity responsible for determining the healthcare services a patient or client may access. The gatekeeper may be a primary care provider, a utilization review or case management agency, or a managed care organization. Geographic practice cost index (GPCI) - CORRECT ANSWERS index based on relative difference in the cost of a market basket of goods across geographic areas; a separate GPCI exists for each element of the relative value unit (RVU), which includes physician work, practice expenses, and malpractice; GPCIs are a means to adjust the RVUs, which are national averages, to reflect local costs of services Grouper - CORRECT ANSWERS Computer program that uses specific data elements to assign patients, clients, or residents to groups, categories, or classes. Guarantor - CORRECT ANSWERS Person who is responsible for paying the bill or guarantees payment for healthcare services. Patients who are adults are often their own guarantor. Parents guarantee payments for the healthcare costs of their children and therefore the guarantor for minors. Hard coding - CORRECT ANSWERS Use of the charge description master to code repetitive or noncomplex services. Health Insurance Portability and Accountability Act (HIPAA) - CORRECT ANSWERS Significant piece of legislation aimed at improving healthcare data transmission among providers and insurers; designated code sets to be used for electronic transmission of claims. Health Maintance Organization (HMO) - CORRECT ANSWERS Entity that combines the provision of healthcare insurance and the delivery of healthcare services. Characterized by (1) organized healthcare delivery system to a Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ geographical area, (2) set of basic and supplemental health maintenance and treatment services, (3) voluntarily enrolled members, and (4) predetermined fixed, periodic prepayments for members' coverage. Prepayments are fixed, without regard to actual costs of healthcare services provided to members. Hierarchical condition category (HCC) - CORRECT ANSWERS Groups of related diagnoses for a patient based on the ICD-10-CM codes assigned. This is a risk adjustment payment methodology used by Medicare advantage plans. The intent of this program is for Centers for Medicarre and Medicaid (CMS) to appropriately pay Medicare advantage plans for their predicted healthcare expenditures based on patient profiles which are calculated using a combination of HCCs (diagnoses) and demographic factors. The information collected during a 12 month period (January-December) is used to calculate a member-specific risk score which is used to adjust rates for the following year. Home Health Agency (HHA) - CORRECT ANSWERS Organization that provides services in the home. These services include skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care by home health aides. Hospital acquired condition (HAC) - CORRECT ANSWERS Condition that developed during the hospital admission In-network - CORRECT ANSWERS providers or health care facilities that are part of a health plan's network of providers with which it has negotiated a discount. Inpatient admission - CORRECT ANSWERS An acute care facility's formal acceptance of a patient who is to be provided with room, board, and continuous nursing service in an area of the facility where patients generally stay at least overnight International classification of diseases, 10th revision, clinical modification (ICD-10- CM/PCS) coding - CORRECT ANSWERS Diagnosis coding is CM, a type of Procedure coding is PCS Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ Length of stay (LOS) - CORRECT ANSWERS The total number of patient days for an inpatient episode, calculated by subtracting the date of admission from the date of discharge Local Coverage Determination (LCD) - CORRECT ANSWERS Reimbursement and medical-necessity policies established by Medicare administrative contractors (MACs). LCDs vary from state to state. Long term care hospital (LTCH) - CORRECT ANSWERS Defined in Medicare law as hospitals that have an average inpatient length of stay greater than 25 days. These hospitals typically provide extended medical and rehabilitative care for patients who are clinically complex and may suffer from multiple acute or chronic conditions. Major Complication and Comorbidity (MCC) - CORRECT ANSWERS Diagnosis codes that when reported as a secondary diagnosis have the potential to impact the MS-DRG assignment by increasing the MS-DRG up one or two levels. MCCs represent the highest level of resource intensity. Major diagnostic category (MDC) - CORRECT ANSWERS Highest level in hierarchical structure of the federal inpatient prospective payment system (IPPS). The 25 MDCs are primarily based on body system involvement, such as MDC No. 06, Diseases and Disorders of the Digestive System. However, a few categories are based on disease etiology, for example, Human Immunodeficiency Virus Infections. Managed care - CORRECT ANSWERS Payment method in which the third party payer has implemented some provisions to control the costs of healthcare while maintaining quality care. Systematic merger of clinical, financial, and administrative processes to manage access, cost, and quality of healthcare Maximum out-of-pocket cost - CORRECT ANSWERS Specific amount, in a certain timeframe, such as one year, beyond which all covered healthcare services for that policyholder or dependent are paid at 100 percent by the healthcare insurance plan. Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ National Coverage Determination (NCD) - CORRECT ANSWERS National medical necessity and reimbursement regulations. Includes a description of the circumstances under which medical supplies, services, or procedures are covered nationwide by Medicare under title XVIII of the Social Security Act and other medical regulations and rulings. Nonparticipating physicians (Non-PARs) - CORRECT ANSWERS Physicians who treat Medicare beneficiaries but do not have a legal agreement with the program to accept assignment on all Medicare services and who, therefore, may bill beneficiaries more than the Medicare reasonable charge on a service-by-service basis. Nonparticipating physicians receive 95% of the full Medicare physician fee schedule amount. Office of the Inspector General (OIG) - CORRECT ANSWERS A division of the Department of Health and Human Services (HHS) that investigates issues of noncompliance in the Medicare and Medicaid programs, such as fraud and abuse. Optimize (MS-DRG) - CORRECT ANSWERS DRG optimization is a term used by hospitals that's striving to obtain optimal reimbursement or the highest possible payment to which the facility is legally entitled based on the coded data supported by clinical documentation in the patient's record. Out of network - CORRECT ANSWERS Providers or suppliers who do not participate in a managed care organization or health plan. Outpatient Code Editor (OCE) - CORRECT ANSWERS Software program designed to process data for OPPS pricing, including executing packaging and bundling logic. Additionally, the OCE edits the claim based on coding and billing requirements. Packaging - CORRECT ANSWERS Occurs when reimbursement for minor ancillary services associated with a significant procedure is combined into a single payment for the procedure. Some services and supplies will be unconditionally packaged (status indicator N); these items will not be separately paid under any circumstances. Other services and supplies will be conditionally packaged (status indicator Q); separate payment may be made for these items depending on what other services are provided on the same date. Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ Participating Physician (PAR) - CORRECT ANSWERS Physician who signs an agreement with Medicare to accept assignment for all services provided to Medicare beneficiaries for the duration of the agreement Payer - CORRECT ANSWERS Payers in the health care industry are organizations — such as health plan providers, Medicare, and Medicaid — that set service rates, collect payments, process claims, and pay provider claims. Payers are usually not the same as providers. Providers are usually the ones offering the services, like hospitals or clinics. Payment status indicator (PSI) - CORRECT ANSWERS Code that establishes how a service, procedure, or item is paid in OPPS. Per diem (per day) payment policy - CORRECT ANSWERS Type of retrospective payment method in which the third-party payer reimburses the provider a fixed rate for each day a covered member is hospitalized. Policy - CORRECT ANSWERS Binding contract issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to treat illness or injury. Policyholder - CORRECT ANSWERS Individual or entity that purchases healthcare insurance coverage. Post-acute-care transfer (PACT) - CORRECT ANSWERS Under IPPS, a transfer to a nonacute-care setting for designated MS-DRGs is treated as an IPPS-to- IPPS transfer when established criteria are met. Preauthorization - CORRECT ANSWERS prior authorization from a payer for services to be provided Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ Premium - CORRECT ANSWERS Amount of money that a policyholder or beneficiary must periodically pay a healthcare insurance company in return for healthcare coverage. Present on Admission (POA) indicator - CORRECT ANSWERS Code used to indicate if the condition or disease was present before the admission or developed during the hospital admission. Required data element for designated diagnosis codes for claims submission Primary Care Provider (PCP) - CORRECT ANSWERS Healthcare provider who provides, supervises, and coordinates the healthcare of a member; primary care physicians can be family and general practitioners, internists, pediatricians, and obstetricians/gynecologists; other PCPs are nurse practitioners and physician assistants Primary insurer (payer) - CORRECT ANSWERS Entity responsible for the greatest proportion or majority of the healthcare expenses. See Secondary insurer. Principal diagnosis - CORRECT ANSWERS Reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Prior approval (preauthorization) - CORRECT ANSWERS Process of obtaining approval from a healthcare insurance company before receiving healthcare services Professional coding - CORRECT ANSWERS Physician outpatient coding. Prospective reimbursement - CORRECT ANSWERS Type of reimbursement in which the third-party payer establishes the payment rates for healthcare services in advance for a specific time period. Qualifying life event - CORRECT ANSWERS Changes in an individual's life that make him/her eligible for a special enrollment period. Examples include moving to a new state, changes in income, and changes in family size. Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ Single Path Coding - CORRECT ANSWERS Process where one coding professional assigns the codes required for both facility and professional claims during the same coding session. Skilled Nursing Facility (SNF) - CORRECT ANSWERS Facility that is certified by Medicare to provide 24-hour skilled inpatient nursing care and rehabilitation services in addition to other medical services for short-term care. Social Security Act (SSA) - CORRECT ANSWERS Federal legislation established in 1935 to provide old-age benefits for workers, unemployment insurance, and aid to dependents and children with physical handicaps. It was amended by Public Law 89-97 on July 30, 1965, to create the Medicare program (title XVIII). Social detriments of health - CORRECT ANSWERS Conditions such as environment and age that impact a wide range of health, functioning, and quality of life outcomes and risks. Soft coding - CORRECT ANSWERS Process in which all diagnoses and procedures are identified, coded, and then abstracted into the HIM coding system. Subscriber - CORRECT ANSWERS The subscriber is the person subscribing to or carrying the insurance plan for the patient case. How is the patient related to the subscriber? For example, if the subscriber is the mother of the patient, then the Patient Relationship to Subscriber is Child. One who writes his or her name at the end of a document, thereby indicating approval; one who regularly receives a magazine, newspaper, etc. Supplemental insurance - CORRECT ANSWERS Additional healthcare insurance that fills in gaps (supplements) in comprehensive insurance or Medicare benefits; may be a cash benefit, per diem, or other form. Third-party payer - CORRECT ANSWERS (1) Insurance company or health agency that pays the physician clinic, or other healthcare provider (second party) Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ for the care or services to the patient (first party). (2) An insurance company or healthcare benefits program that reimburses healthcare providers and patients for covered medical services. Transparency - CORRECT ANSWERS Transparency for the patient is having the knowledge of how much the procedures are going to cost before the patient has them. That way, he or she can make an informed decision based on that information. The truth is that very few patients know what they're going to have to pay for their healthcare until it's too late. The presentation of a company's facts and figures in a way that is clear and apparent to all stakeholders. TRICARE - CORRECT ANSWERS The healthcare program for active duty and retired members of one of the eight uniformed services administered by the Department of Defense; formerly known as Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). Unbundling - CORRECT ANSWERS The fraudulent process in which individual component codes are submitted for reimbursement rather than one comprehensive code. Upcoding - CORRECT ANSWERS The fraudulent process of submitting codes for reimbursement that indicate more complex or higher-paying services than those that the patient actually received. Utilization Management (UM) - CORRECT ANSWERS A program that evaluates the healthcare facility's efficiency in providing necessary care to patients in the most effective manner. Value-based purchasing (VBP) - CORRECT ANSWERS Payment model that holds healthcare providers accountable for both the cost and quality of care they provide. Variance Analysis - CORRECT ANSWERS Variance analysis compares a standard of performance against actual results and investigates those differences that are felt to be the result of inefficient performance. Healthcare Revenue Management Final Exam 170questions and answers 100%correctly Verified 2024/2025 RATED A+ Veterans Health Administration (VA) - CORRECT ANSWERS Integrated healthcare delivery system dedicated to providing healthcare services to American veterans. Wage index - CORRECT ANSWERS Ratio that represents the relationship between the average wages in a healthcare setting's geographic area and the national average for that healthcare setting. Wage indexes are adjusted annually and published in the Federal Register. Waiting period - CORRECT ANSWERS Period, generally not exceeding 90 days, that must pass before coverage for an employee or dependent who is otherwise eligible to enroll under the terms of a group health plan can become effective. Workers Compensation - CORRECT ANSWERS Medical and income insurance coverage for employees who suffer from a work-related injury or illness. Claim denial management - CORRECT ANSWERS The process of identifying and reviewing specific reasons for claim denials, followed by development of a process for appealing denied claims when appropriate. Delinquent claim - CORRECT ANSWERS An insurance claim submitted to an insurance company for which payment is overdue; usually this is a claim which was not paid within 30-45 days of service. The claim filing and payment timeline should be specified in the contract between healthcare provider and the payer. Denied claim - CORRECT ANSWERS An insurance claim submitted to an insurance company in which payment has been rejected due to a technical error or because of medical coverage policy issues. Dirty claim - CORRECT ANSWERS A claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment.