HFMA CRCR Exam Practice Questions and Answers, Exams of Nursing

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HFMA CRCR EXAM, CERTIFICATION EXAM, PRACTICE EXAM AND A STUDY GUIDE LATEST 2024 ACTUAL EXAM 600 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+ It is important to have high registration quality standards because a) Inaccurate or incomplete pt data will delay payment or cause denials b) Incomplete registrations will trigger exclusion from Medicare participation c) Inaccurate registration may cause discharge before full treatment is obtained d) Incomplete registrations will raise satisfaction scores for the hospital - ....ANSWER...A When recovery audit contractors (RAC) identify improper payments as over payments the claims processing contractor must a) Assume legal responsibility for repaying the overage amount b) Make recovery of the overpayment the top processing priority c) Send a demand letter to the provider to recover the over payment amount d) Conduct an audit of all the effected providers claims within the past 12 months - ....ANSWER...C Internal controls addressing coding and reimbursement changes are put I place to guard against a) Underpayments b) Denials c) Compliance fraud by upcoding d) Charge master error - ....ANSWER...C The pt discharge process begins when a) The physician writes the discharge orders b) Clinical services are completed and pt accounts have all the info necessary to bill c) The physician writes the discharge orders and the third-party payer sign-off on the necessity of the services provided d) Clinical services are completed, pt accounts can generated and accurate bill and there is agreement o the handling of pt financial responsibilities - ....ANSWER...A Most major health plans including medicare and Medicaid, offer a) Toll free verification hot lines, staffed around the clock b) Electronic and/or web portal verification c) Pt "verification of benefits" cards d) A grace period for obtaining verification within 72 hours of treatment - ....ANSWER...B The physician who wrote the order for an inpatient service and is in charge of the pts treatment during admission is a) The pts personal physician b) The primary care physician c) The attending physician d) The physician pt care director - ....ANSWER...C An originating site is a) The location where the pts bill is generated b) The location of the pt at the time the service is provided c) The site that generates reimbursement of a claim d) The location of the medical treatment provider - ....ANSWER...B HFMA best practices stipulate that a reasonable attempt should be made to have the What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - ....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? - ....ANSWER...Bad debt adjustment What is the initial hospice benefit? - ....ANSWER...Two 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - ....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? - ....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 - ....ANSWER...They are not being processed in a timely manner What is an advantage of a preregistration program? - ....ANSWER...It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - ....ANSWER...Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - ....ANSWER...Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts What statement applies to the scheduled outpatient? - ....ANSWER...The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - ....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? - ....ANSWER...Observation What are collection agency fees based on? - ....ANSWER...A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - ....ANSWER...Birthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - ....ANSWER...Case rates What customer service improvements might improve the patient accounts department? - ....ANSWER...Holding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - ....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? - ....ANSWER...Bad debt adjustment What is the initial hospice benefit? - ....ANSWER...Two 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - ....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? - ....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 - ....ANSWER...They are not being processed in a timely manner What is an advantage of a preregistration program? - ....ANSWER...It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - ....ANSWER...Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - ....ANSWER...Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts What statement applies to the scheduled outpatient? - ....ANSWER...The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - ....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? - ....ANSWER...Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - ....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$? - ....ANSWER...When the patient is the insured In addition to being supported by information found in the patient's chart, a CMS 1500 claim must be coded using what? - ....ANSWER...HCPCS (Healthcare Common Procedure Coding system) What results from a denied claim? - ....ANSWER...The provider incurs rework and appeal costs Why does the financial counselor need pricing for services? - ....ANSWER...To calculate the patient's financial responsibility What type of provider bills third-party payers using CMS 1500 form - ....ANSWER...Hospital-based mammography centers How are disputes with nongovernmental payers resolved? - ....ANSWER...Appeal conditions specified in the individual payer's contract The important message from Medicare provides beneficiaries with information concerning what? - ....ANSWER...Right to appeal a discharge decision if the patient disagrees with the services Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - ....ANSWER...To improve access to quality healthcare If a patient remains an inpatient of an SNF (skilled nursing facility for more than 30 days, what is the SNF permitted to do? - ....ANSWER...Submit interim bills to the Medicare program. 90. MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - ....ANSWER...120 days passes, but the claim then be withdrawn from the liability carrier Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - ....ANSWER...Medically necessary inpatient hospital services for at least 3 consecutive days before the skilled nursing care admission When is the word "SAME" entered on the CMS 1500 billing form in Field 0$? - ....ANSWER...When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - ....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? - ....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? - ....ANSWER...Disclosure rules for consumer credit sales and consumer loans What is a principal diagnosis? - ....ANSWER...Primary reason for the patient's admission Collecting patient liability dollars after service leads to what? - ....ANSWER...Lower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - ....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? - ....ANSWER...Inpatient care What code indicates the disposition of the patient at the conclusion of service? - ....ANSWER...Patient discharge status code What are hospitals required to do for Medicare credit balance accounts? - ....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? - ....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: - ....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? - ....ANSWER...Access their information and perform functions on-line What date is required on all CMS 1500 claim forms? - ....ANSWER...onset date of current illness What does scheduling allow provider staff to do - ....ANSWER...Review appropriateness of the service request What code is used to report the provider's most common semiprivate room rate? - ....ANSWER...Condition code Regulations and requirements for coding accountable care organizations, which allows providers to begin creating these organizations, were finalized in: - ....ANSWER...2012 What is a primary responsibility of the Recover Audit Contractor? - ....ANSWER...To correctly identify proper payments for Medicare Part A & B claims How must providers handle credit balances? - ....ANSWER...Comply with state statutes concerning reporting credit balance What is a benefit of pre-registering patient's for service? - ....ANSWER...Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - ....ANSWER...Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - ....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? - ....ANSWER...Blue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? - ....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? - ....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? - ....ANSWER...Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? - ....ANSWER...Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - ....ANSWER...Code of conduct How does utilization review staff use correct insurance information? - ....ANSWER...To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - ....ANSWER...As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - ....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? - ....ANSWER...Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - ....ANSWER...Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail How are patient reminder calls used? - ....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? - ....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? - ....ANSWER...Sale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - ....ANSWER...A condition code What option is an alternative to valid long-term payment plans? - ....ANSWER...Bank loans What is an advantage of using a collection agency to collect delinquent patient accounts? - ....ANSWER...Collection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? - ....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 - ....ANSWER...catastrophic charity What happens when a patient receives non-emergent services from and out-of-network provider? - ....ANSWER...Patient payment responsibility is higher Every patient who is new to the healthcare provider must be offered what? - ....ANSWER...A printed copy of the provider's privacy notice How may a collection agency demonstrate its performance? - ....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? - ....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? - ....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? - ....ANSWER...Obtain the required demographic and insurance information before services are rendered professional. Intended to ensure continuity of healthcare accessibility and services Claim - ....ANSWER...A demand by an insured person for the benefits provided by the group contract Coordination of benefits (COB) - ....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 - ....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 - ....ANSWER...Patient status regarding coverage for healthcare insurance benefits First dollar coverage - ....ANSWER...A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses Gatekeeping - ....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 - ....ANSWER...an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - ....ANSWER...negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary - ....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 - ....ANSWER...healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out-of-pocket payments - ....ANSWER...Cash payments made by the insured for services not covered by the health insurance plan Pre-admission review - ....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 - ....ANSWER...A restriction on payments for charges directly resulting from a pre-existing health conditions Same-day admission - ....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 - ....ANSWER...Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Subrogation - ....ANSWER...Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses Subscriber - ....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 - ....ANSWER...A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery Third-part administrator (TPA) - ....ANSWER...Provides services to employers or insurance companies for utilization review, claims payment and benefit design Third-party reimbursement - ....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) - ....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 - ....ANSWER...Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Charge - ....ANSWER...The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Cost - ....ANSWER...The definition of cost varies by party incurring the expense Price - ....ANSWER...the total amount a provider expects to be paid by payers and patients for healthcare services Care purchaser - ....ANSWER...Individual or entity that contributes to the purchase of healthcare services Payer - ....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 - ....ANSWER...An entity, organization, or individual that furnishes a healthcare service Specific to Medicare fee-for-service patients, which of the following payers have always been liable for payment? - ....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: - ....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. What is the intended outcome of collaborations made through an ACO delivery system for a population of patients? - ....ANSWER...To eliminate duplicate services, prevent medical errors and ensure appropriateness of care. Historically, revenue cycle has delt with contractual adjustments, bad debt and charity deductions from gross revenue. Although deductions continue to exist, the definition of net revenue has been modified through the implementation of ASC 606. Developed by the Financial Accounting Standards Board (FASB), this change became effective in 2018. What is the new terminology now employed in the calculation of net patient services revenues? - ....ANSWER...Explicit prices concessions and implicit price concessions Key performance indicators set standards for A/R and provide a method for measuring the control and collection of A/R. What are the two KPIs used to monitor performance related to the production and submission of claims to third party payers and patients (self-pay)? - ....ANSWER...Elapsed days from discharge to final bill and elapsed days from final bill to claim/bill submission. Consents are signed as part of the post-services process. - ....ANSWER...True **False Patient service costs are calculated in the pre-service process for schedule patients - ....ANSWER...**True False The patient is scheduled and registered for service is a time-of-service activity - ....ANSWER...True **False The patient account is monitored for payment is a time-of-service activity - ....ANSWER...True **False Case management and discharge planning services are a post-service activty - ....ANSWER...True **False Sending the bill electronically to the health plan is a time-of-service activity - ....ANSWER...True **False What happens during the post-service stage? - ....ANSWER...**A. Final coding of all services, preparation and submission of claims, payment processing and balance billing and resolution. B. Orders are entered, results are reported, charges are generated, and diagnostic and procedural coding is initiated. C. The encounter record is generated, and the patient and guarantor information is obtained and/or updated as required. D. The focus is on the patient and his/her financial care, in addition to the clinical care provided for the patient. The following statements describe best practices established by the Medical Debt Task Force. Check the box next to the True statements - ....ANSWER...**Educate Patients **Coordinate to avoid duplicate patient contacts Exercise moderate judgement when communicating with providers about scheduled services **Be consistent in key aspects of account resolution Report to healthcare plans when the patient's account is transferred to collection agency **Follow best practices for communication Which option is NOT a main HFMA Healthcare Dollars & Sense® revenue cycle initiative? - ....ANSWER...A. Patient Financial Communications B. Price Transparency C. Medical Account Resolution **D. Process Compliance What is the objective of the HCAHPS initiative? - ....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? - ....ANSWER...A. Information Technology B. Clinical Services C. Finance 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: - ....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. What are KPIs? - ....ANSWER...A. Benchmarks which are used to compare Key Performance Indicators in an organization to an agreed upon average or expected standard within the same industry. **B. Key performance indicators, which set standards for accounts receivable (A/R) and provide a method of measuring the collection and control of A/R. C. Days in A/R is calculated based on the value of the total accounts receivable on a specific date. D. A component that can divide the accounts receivable into 30, 60, 90, 120 days, and over 120 days categories, based on the date of service/discharge While the highest level of differentiation among patients is scheduled patient vs unscheduled patient, a variety of patient types are routinely identified in both the acute and non-acute settings. Which patient types are typically considered acute care patient types? - ....ANSWER...Observation, newborn, Emergency (ED) Accurate identification of the patient is the first step in the scheduling process. Identifiers used in various combination to achieve accurate patient identification include? - ....ANSWER...Full legal name, date of birth, sex and social security number Pre-registration is defined as: - ....ANSWER...The collection of demographic information, insurance data, financial information, providing reminders, prep information, and identifying the potential need for financial assistance for scheduled patients. Medicare has unique features not found in other health plan programs. It is government sponsored and financed through taxes and general revenue funds. Which of the following statements accurately describes the various Medicare benefits programs: - ....ANSWER...Medicare Part A provides benefits for inpatient hospital services, skilled nursing care and home health care; Medicare Part B covers outpatient and professional services, Medicare Part C or Medicare Advantage plans are managed care plans combining Part A and Part B Coverages; and Medicare Part D is the prescription drug coverage benefit. Which of the following statements about Medicaid eligibility is not true? - ....ANSWER...Medicaid categories are restricted to children, pregnant women and elderly in nursing homes. Examples of managed care plans include: - ....ANSWER...All of the above Patient Financial Communications best practices include all of the following activities except: - ....ANSWER...Collecting payment or initiating the process to immediately remove the patient from the service schedule. HFMA CRCR CERTIFICATION Which statement includes the required components of an accurate pricing determination? - ....ANSWER...Insurance coverage and benefits, service or test involved, diagnosis and procedure codes, total estimated charges, adjudication calculations based on the patient's benefit package. The value of a robust scheduling and pre-registration process includes all of the following except: - ....ANSWER...Identification of patients who are likely to be "no shows". Which patients are considered scheduled? - ....ANSWER...A. Observation Patients B. Emergency Department Patients **C. Recurring/Series Patients D. Hospice Care Name the guideline that Medicare established to determine which diagnoses, signs, or symptoms are payable. - ....ANSWER...A. Patient Identifiers **B. Local Coverage Determinations C. Advance Beneficiary Notice D. Scheduling Instructions What is the purpose of insurance verification? - ....ANSWER...A. To identify information that does not have to be collected from the patient. **B. To ensure accuracy of the health plan information. C. To effectively complete the MSP screening process. D. To complete guarantor information if the guarantor is not the patient. in healthcare are: - ....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: - ....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: - ....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: - ....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: - ....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: - ....ANSWER...Payers will waive timely filing denials for claims filed over a year from date of service. What does EMTALA require hospitals to do? - ....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? - ....ANSWER...A. By reviewing a patient's individual case and recommend treatment changes. B. With monitoring the progression of high resource consumptive cases. C. By estimating how long the patient will be in the hospital and what the expected outcome will be. **D. Providing assistance with written appeals to health plans related to utilization and other care issues. Why is it critical that a chargemaster is reviewed and updated regularly? - ....ANSWER...**A. To ensure it supports and represents the services provided within the organization. B. To ensure the most appropriate measure of the utilization of resources. C. So the CPT databases can have the most current and accurate information. D. Because charge descriptions can vary greatly between providers. What is the responsibility of HIM? - ....ANSWER...**A. To maintain all patient medical records B. To make information available instantly and securely to authorized users C. To denote the medical procedures performed by a healthcare provider on a patient D. To substantiate health insurance claims filed by the patient, the physician, and the provider What are claim edits? - ....ANSWER...A. Various data sources including Medicare and Medicaid bulletins and manuals, individual health plan manuals B. A multi-stakeholder collaboration of more than 130 organizations — providers, health plans, vendors, and government agencies **C. Rules developed to verify the accuracy and completeness of claims based on each health plan's policies D. The submission, receipt, and processing of automated claims, thereby eliminating mail time and reducing data entry time Which statement is NOT a unique billing rule specific to providers? - ....ANSWER...A. Overall aggregate payments made to a hospice are subject to a "cap amount", calculated by the MAC at the end of the hospice cap period. B. With the exception of physician services, Medicare reimbursement for hospice care is made at one of four pre-determined rates for each day of hospice care. C. When billing services on a UB-04/837-I, specific CPT codes are collapsed into a single revenue code (520 or 521). **D. A patient may be balance billed for whatever amount the non- contracting physician charges above the health plan's reimbursement amount. Which of the following statements does not apply to billing during the COVID-19 public health emergency: - ....ANSWER...A. Hospitals may change a sub-acute unit into an acute care unit without advanced approval from CMS. **B. Telemedicine claims are not payable if the patient conducts the telemedicine visit from home. C. CMS developed the concept of hospitals without walls to increase ICU and med-surge inpatient capacity during the COVID-19 pandemic. vendor's staff represents themselves as employees of the healthcare facility. HFMA CRCR PRACTICE EXAM 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? - ....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: - ....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? - ....ANSWER...**A. Manually match the ERA to the patient account. B. Nothing unless there is an error. What is EFT? - ....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? - ....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? - ....ANSWER...A. Technical B. Clinical C. Underpayment **D. Contractual Adjustment Which option is NOT a lien type? - ....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? - ....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? - ....ANSWER...A. Eligibility criteria B. Application process C. Application assistance **D. Out-of-network providers Which option is NOT a bankruptcy type governed by the 1979 Bankruptcy Act? - ....ANSWER...A. Straight bankruptcy B. Debtor reorganization **C. Creditor priority D. Debtor rehabilitation Which evaluation criteria demonstrates reputation expectations: - ....ANSWER...A. The agency's Yelp score and consumer comments. B. The amount of monies collected monthly. **C. The employment of staff who have documented experience working in financial areas of health care. D. The high turnover rate for entry level employees. Agency fees are: - ....ANSWER...A. Paid by patients. **B. The cost to the provider for collection agency monies offset by the return on baddebt accounts. C. Only reported annually to the provider. D. Waived for accounts aged greater than one year from date of service. The correct way to handle the retention and payment of agency fees is: - ....ANSWER...A. The agency provides an annual settlement of monies received by the health care provider and the agency. B. Compare estimated collection costs to actual costs incurred. C. Validate bank deposits weekly as funds are received from the agency. **D. Follow the contractual agreement between the agency and the provider as to how monies sent to the agency will be handled. True or False: The following statement represents an advantage of outsourcing: Ineffective vendor results in increased costs - ....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? - ....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? - ....ANSWER...**A. Health Care Patient Services B. Patient Accounting C. Patient Access D. Health Information Management Through what document does a hospital establish compliance standards? - ...ANSWER...code of conduct What is the purpose OIG work plant? - ...ANSWER...Identify Acceptable compliance programs in various provider setting What data are required to establish a new MPI entry? - ....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? - ....ANSWER...Determine the correct payer and notify the incorrect payer of the processing error What do EMTALA regulations require on-call physicians to do? - ....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? - ....ANSWER...They must be balanced What will cause a CMS 1500 claim to be rejected? - ....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? - ....ANSWER...The cost of the test how are HCPCS codes and the appropriate modifiers used? - ....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? - ....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? - ....ANSWER...Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - ....ANSWER...Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - ....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? - ....ANSWER...Blue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? - ....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? - ....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? - ....ANSWER...Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? - ....ANSWER...Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - ....ANSWER...Code of conduct How does utilization review staff use correct insurance information? - ....ANSWER...To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - ....ANSWER...As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - ....ANSWER...The services will be documented in the wrong record Payment System) hospital, what must happen to these charges - ....ANSWER...They must be combined with the inpatient bill and paid under the MS-DRG system What do large adjustments require? - ....ANSWER...Manager-level approval What items are valid identifiers to establish a patient's identification? - ....ANSWER...Photo identification, date of birth, and social security number What must a provider do to qualify an account as a Medicare bad debts? - ....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? - ....ANSWER...Site-of-service limitation What is an example of an outcome of the Patient Friendly Billing Project? - ....ANSWER...Redesigned patient billing statements using patient-friendly language What statement describes the APC (Ambulatory payment classification) system? - ....ANSWER...APC rates are calculated on a national basis and are wage-adjusted by geographic region What is a benefit of insurance verification? - ....ANSWER...Pre- certification or pre-authorization requirements are confirmed What is an effective tool to help staff collect payments at the time of service? - ....ANSWER...Develop scripts for the process of requesting payments What is a benefit of electronic claims processing? - ....ANSWER...Providers can electronically view patient's eligibility What does Medicare Part D provide coverage for? - ....ANSWER...Prescription drugs What are some core elements of a board-approved financial policy - ....ANSWER...Charity care, payment methods, and installment payment guidelines What circumstance would result in an incorrect nightly room charge? - ....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? - ....ANSWER...Does not include required modifiers Access - ....ANSWER...An individual's ability to obtain medical services on a timely and financially acceptable level Administrative Services Only (ASO) - ....ANSWER...Usually contracted administrative services to a self-insured health plan Case management - ....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 - ....ANSWER...A demand by an insured person for the benefits provided by the group contract Coordination of benefits (COB) - ....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 - ....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 - ....ANSWER...Patient status regarding coverage for healthcare insurance benefits First dollar coverage - ....ANSWER...A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses Gatekeeping - ....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 - ....ANSWER...an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - ....ANSWER...negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary - ....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 - ....ANSWER...healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out-of-pocket payments - ....ANSWER...Cash payments made by the insured for services not covered by the health insurance plan Pre-admission review - ....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 - ....ANSWER...A restriction on payments for charges directly resulting from a pre-existing health conditions What areas does the code of conduct typically focus on? - ....ANSWER...Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations FERA - ....ANSWER...Fraud Enforcement and Recovery act ESRD - ....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? - ....ANSWER...Mitigate potential fraud and abuse in the industry- specific key risk areas What is important about an effective corporate compliance program? - ....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 - ....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? - ....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. - ....ANSWER...TRUE The OIG has issued compliance guidance/model compliance plans for all of the following entities: - ....ANSWER...hospices. physician practices. ambulance providers Providers who are found to be in violation of CMS regulations are subject to: - ....ANSWER...Corporate integrity agreements What MSP situation requires LGHP - ....ANSWER...Disability The disadvantages of outsourcing include all of the following EXCEPT: a) The impact of customer service or patient relations b) The impact of loss of direct control of accounts receivable services c) Increased costs due to vendor ineffectiveness d) Reduced internal staffing costs and a reliance on outsourced staff - ....ANSWER...D The Medicare fee-for service appeal process for both beneficiaries and providers includes all of the following levels EXCEPT: a) Medical necessity review by an independent physician's panel b) Judicial review by a federal district court c) Redetermination by the company that handles claims for Medicare d) Review by the Medicare Appeals Council (Appeals Council) - ....ANSWER...B Business ethics, or organizational ethics represent: a) The principles and standards by which organizations operate b) Regulations that must be followed by law c) Definitions of appropriate customer service d) The code of acceptable conduct - ....ANSWER...A A portion of the accounts receivable inventory which has NOT qualified for billing includes: a) Charitable pledges b) Accounts created during pre-registration but not activated c) Accounts coded but held within the suspense period d) Accounts assigned to a pre-collection agency - ....ANSWER...A Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) are Medicare established guideline(s) used to determine: a) Medicare and Medicaid provider eligibility b) Medicare outpatient reimbursement rates c) Which diagnoses, signs, or symptoms are reimbursable d) What Medicare reimburses and what should be referred to Medicaid - ....ANSWER...C Days in A/R is calculated based on the value of: a) The total accounts receivable on a specific date b) Total anticipated revenue minus expenses c) The time it takes to collect anticipated revenue d) Total cash received to date - ....ANSWER...C 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: a) That hospitals don't want to establish a price without knowing if the patient has insurance and how much reimbursement can be expected b) The fact that charge master lists the total charge, not net charges that reflect charges after a payer's contractual adjustment c) That hospitals don't want to be put in the position of "guaranteeing" price without having room for additional charges that may arise in the course of treatment c) Scheduling, registration, charge entry and managed care processing d) Scheduling, pre-registration, registration, medical necessity screening and patient refunds - ....ANSWER...A Which of the following is NOT contained in a collection agency agreement? a) A clear understanding that the provider retains ownership of any outsourced activities b) Specific language as to who will pay legal fees, if needed c) An annual renewal clause d) A mutual hold-harmless clause - ....ANSWER...D Maintaining routine contact with the health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of: a) Patient Accounts b) Managed Care Contract Staff c) HIM staff d) Case Management - ....ANSWER...D What is required for the UB-04/837-I, used by Rural Health Clinics to generate payment from Medicare? a) Revenue codes b) Correct Part A and B procedural codes c) The CMS 1500 Part B attachment d) Medical necessity documentation - ....ANSWER...A Before classifying and subsequently writing off an account to financial assistance or bad debt, the hospital must establish policy, define appropriate criteria, implement procedures for identifying and processing accounts: a) Monitor compliance b) Have the account triaged for any partial payment possibilities c) Assist in arranging for a commercial bank loan d) Obtain the patients income tax statements from the prior 2 years - ....ANSWER...A For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions: a) Are optional b) Should take place between the patient or guarantor and properly trained provider representatives c) May take place between the patient and discharge planning d) Are focused on verifying required third-party payer information - ....ANSWER...B The purpose of a financial report is to: a) Provide a public record, if reqluested b) Present financial information to decision makers c) Prepare tax documents d) Monitor expenses - ....ANSWER...B Which statement is an EMTALA (Emergency Medical Treatment and Active Labor Act) violation? a) Registration staff may routinely contact managed are plans for prior authorizations before the patient is seen by the on-duty physician b) Initial registration activities may occur so long as these activities do not delay treatment or suggest that treatment with not be provided to uninsured individuals c) Co-payments may be collected at the time of service once the medical screening and stabilization activities are completed d) Signage must be posted where it can be easily seen and read by patients - ....ANSWER...A A claim is denied for the following reasons, EXCEPT: a) The health plan cannot identify the subscriber b) The frequency of service was outside the coverage timeline c) The submitted claim does not have the physicians signature d) The subscriber was not enrolled at the time of service - ....ANSWER...C 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 a) A court appointed federal mediator b) The Department of Health and Human Services Provider Relations Division c) The Office of the Inspector General d) The Provider Reimbursement Review Board - ....ANSWER...D Charges, as the most appropriate measurement of utilization, enables a) Generation of timely and accurate billing b) Managing of expense budgets c) Accuracy of expense and cost capture d) Effective HIM planning - ....ANSWER...???Number 24??? Ambulance services are billed directly to the health plan for a) All pre-admission emergency transports b) 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 c) The portion of the bill outside of the patient's self-pay d) Transports deemed medically necessary by the attending Medicare beneficiaries remain in the same "benefit period" a) Up to hospitalization discharge b) Until the beneficiary is "hospitalization and/or skilled nursing facility-free" for 60 consecutive days c) Each calendar year d) Up to 60 days - ....ANSWER...B Key Performance Indicators (KPIs) set standards for accounts receivables (A/R) and a) Provide evidence of financial status b) Provide a method of measuring the collection and control of A/R c) Establish productivity targets d) Make allowance for accurate revenue forecasting - ....ANSWER...B Recognizing that health coverage is complicated and not all patients are able to navigate this terrain, HFMA best practices specify that a) The patient accounts staff have someone assigned to research coverage on behalf of patients b) Patients should be given the opportunity to request a patient advocate, family member, or other designee to help them in these discussions c) Patient coverage education may need to be provided by the health plan d) A representative of the health plan be included in the patient financial responsibilities discussion - ....ANSWER...B When there is a request for service, the scheduling staff member must confirm the patient's unique identification information to a) Check if there is any patient balance due b) Verify the patient's insurance coverage if the patient is a returning customer c) Confirm that physician orders have been received d) Ensure that she/he accesses the correct information in the historical database - ....ANSWER...D Once the price is estimated in the pre-service stage, a provider's financial best practice is to a) Explain to the patient their financial responsibility and to determine the plan for payment b) Allow the patient time to compare prices with other providers c) Lock-in the prices d) Have another employee double check the price estimate - ....ANSWER...A What type of account adjustment results from the patient's unwillingness to pay a self- pay balance? a) Charity adjustment b) Bad debt adjustment c) Contractual adjustment d) Administrative adjustment - ....ANSWER...B All of the following are conditions that disqualify a procedure or service from being paid for by Medicare EXCEPT a) Medically unnecessary b) Not delivered in a Medicare licensed care setting c) Offered in an outpatient setting d) Services and procedures that are custodial in nature - ....ANSWER...D All of the following are forms of hospital payment contracting EXCEPT a) Contracted Rebating b) Per Diem Payment c) Fixed Contracting d) Bundled Payment - ....ANSWER...A Overall aggregate payments made to a hospice are subject to a computed "cap amount" calculated by: a) The Center for Medicare and Medicaid Services (CMS) b) Each state's Medicaid plan c) Medicare d) The Medicare Administrative Contractor (MAC) at the end of the hospice cap period - ....ANSWER...D With the advent 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 a) Reschedule the visit for non-payment of a prior balance b) Strictly limit charity care and bad-debt c) Collect patient's self-pay and deductibles in the first encounter d) Assist patients in understanding their insurance coverage and their financial obligation - ....ANSWER...D A nightly room charge will be incorrect if the patient's a) Discharge for the next day has not been charted b) Condition has not been discussed during the shift change report meeting c) Pharmacy orders to the ICU have not been entered in the pharmacy system d) Transfer from ICU (intensive care unit) to the Medical/Surgical floor is not reflected in the registration system - ....ANSWER...D party is notified or the patient applies for financial assistance with the first 48 hours c) The remaining registration processing is initiated at the bedside or in a registration area d) An initial registration records is completed so that the proper coding can be initiated - ....ANSWER...C This directive was developed to promote and ensure healthcare quality and value and also to protect consumers and workers in the healthcare system. This directive is called a) Payer quality monitoring b) Medicare patient and staff safety standards c) Joint Commission for Accreditation of Healthcare Organizations (JCAHO) safety d) Patient bill of rights - ....ANSWER...D A scheduled inpatient represents an opportunity for the provider to do which of the following? a) Refer the patient to another location with the health system b) Comply with EMTALA (Emergency Medical Treatment and Labor Act) requirements before service c) Complete registration and insurance approval before service d) Register the patient after he or she is placed in a bed on that service unit. - ....ANSWER...C The first and most critical step in registering a patient, whether scheduled or unscheduled, is a) Having the patient initial the HIPAA privacy statement b) Verifying insurance to activate the patient medical record c) Verifying the patient's identification d) Check the schedule for treatment availability - ....ANSWER...C The legal authority to request and analyze provider clam documentation to ensure that IPPS services were reasonable and necessary is given to a) Recovery Audit Contractors (RAC) b) The Office of the U.S. Inspector General (OIG) c) All health plans d) State insurance commissioners - ....ANSWER...B An advantage of a pre-registration program is a) The opportunity to reduce processing times at the time of service b) The ability to eliminate no-show appointments c) The opportunity to reduce the corporate compliance failures within the registration process d) The marketing value of such a program - ....ANSWER...C Claims with dates of service received later than one calendar year beyond the date of service, will be a) Denied by Medicare b) The provider's responsibility but can be deemed charity care c) Fully paid with interest d) The full responsibility of the patient. - ....ANSWER...A This concept encompasses all activities required to send a request for payment to a third-party health plan for payment of benefits a) Third-party invoicing b) Account resolution c) Claims processing d) Billing - ....ANSWER...C The ACO investment model will test the use of pre-paid shared savings to a) Raise quality ratings in designated hospitals. b) Encourage new ACOs to form in rural and underserved areas c) Attract physicians to participate in the ACO payment system d) Invest in treatment protocols that reduce costs to Medicare - ....ANSWER...B Chapter 13 Bankruptcy, debtor rehabilitation, is a court proceeding a) That establishes a payment priority order to creditors' claims b) That classifies the debtor as eligible for government financial assistance for housing, medical treatment and food as debts are paid c) That creates a clear court-supervised payment accountability plan going forward d) That reorganizes a debtor's holdings and instructs creditors to look to the debtor's future earnings for payment - ....ANSWER...D HFMA's patient financial communication best practices specify that patients should be told about the types of services provided and a) A satisfaction survey regarding clinical service providers b) The price of service to their covering health plan c) The service providers that typically participate in the service, e.g., radiologists, pathologists, etc. d) An expiration of why a specific service is not provided - ....ANSWER...C The important Message from Medicare provides beneficiaries information concerning their c) Patients an overview of services covered by their health insurance plan d) The specificity and coding needed to support reimbursement claims - ....ANSWER...D A recurring/series registration is characterized by a) A creation of multiple registrations for multiple services b) The creation of one registration record for multiple days of service c) The creation of multiple patient types for one date of service d) The creation of one registration record per diagnosis per visit - ....ANSWER...B 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? a) Complete course of treatment b) Medical screening and stabilizing treatment c) Admission to observation status d) Transfer to another facility - ....ANSWER...B In resolving medical accounts, a law firm may be used as: a) An independent auditor of a financial assistance policy b) Legal counsel to patients regarding financing options c) An independent broker of patient financial assistance from banks d) A substitute for a collection agency - ....ANSWER...D The unscheduled "direct" admission represents a patient who: a) Is admitted from a physician's office on an urgent basis b) Arrives at the hospital via ambulance for treatment in the emergency room c) Is an ambulatory patient who collapses in the hospital lobby d) Arrives on the medical helicopter for trauma services - ....ANSWER...A In the balance resolution process, providers should: a) Stress to the patient that serious consequences may result from refusal to pay b) Remind the patient of their legal responsibility to pay the balance due c) Ask the patient if he or she would like to receive information about payment options and supportive financial assistance programs d) Tag the patients record for possible financial assistance for bad debt - ....ANSWER...C Which of the following in NOT included in the Standardized Quality Measures a) Clinical outcomes b) Patient perceptions c) Health care processes d) Cost of services - ....ANSWER...D In the pre-service stage, the requested service is screened for medical necessity, health plan coverage and benefits are verified and: a) Billing authorization is signed by the patient b) The patient signs the consents for treatment c) The patient signs a statement attesting an understanding and acceptance of payment policies d) Pre-authorization are obtained - ....ANSWER...D Improving the overall patient experience requires revenue cycle leadership and staff to simultaneously be: a) Clear on policies and consistent in applying the policies b) Careful in screening patient demands c) Monitoring the costs and charges the patient incurs d) Inquisitive, responsive and flexible - ....ANSWER...A Hospitals need which of the following information sets to assess a patient's financial status: a) Income, expenses, debt b) Patient and guarantor's income, expenses and assets c) Income, expenses and capacity to take on more debt d) Assets liquidity, Income, expenses, credit worthiness - ....ANSWER...B For scheduled patients, important revenue cycle activities I the Time of Service stage DO NOT INCLUDE: a) Pre-registration record is activated, consents are signed, and co- payment is collected b) Positive patient identification is completed, and patient is given an armband c) Final bill is presented for payment d) Preprocessed patients may report to a designated "express arrival" desk - ....ANSWER...C The Electronic Remittance Advice (ERA) data set is : a) Used for Electronic Funds Transfers between hospitals and a bank b) A standardized form that provides 3rd party payment details to providers c) Required for annual Medicare quality reporting forms d) Safeguards the Electronic claims process - ....ANSWER...B Appropriate training for patient financial counseling staff must cover all of the following EXCEPT: a) Patient financial communications best practices specific to staff role b) Financial assistance policies c) Documenting the conversation in the medical records d) Available patient financing options - ....ANSWER...C d) Check if any patient balance due - ....ANSWER...B 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 education/resolution are all a) The data collection steps for scheduling and pre-registering a patient b) Registration steps that must be completed before any medical services are provided c) The steps mandated for billing Medicare Part A d) The process of closing an account - ....ANSWER...A Insurance verification results in which of the following a) The accurate identification of the patient's eligibility and benefits b) The consistent formatting of the patient's name and identification number The resolution of managed care and billing requirements The identification of physician fee schedule amounts and the NPI (national provider identifier) numbers - ....ANSWER...A 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 a) HCPCs codes b) ICD-10 Procedural codes c) CPT codes d) Revenue codes - ....ANSWER...D The importance of Medical records being maintained by HIM is that the patient records: a) Are evidence used in assessing the quality of care b) Are the primary source for clinical data required for reimbursement by health plans and liability payers C) Are the strongest evidence and defense in the event of a Medicare Audit d) Are the evidence cited in quality review - ....ANSWER...B Medicare patients are NOT required to produce a physician order to receive which of these services a) Diagnostic Mammography, flu vaccine, or B-12 shots b) Diagnostic Mammography, flu vaccine, or pneumonia vaccine c) Screening Mammography, flu vaccine or pneumonia vaccine d) Screening Mammography, flu vaccine or B-12 shots - ....ANSWER...C Patients should be informed that costs presented in a price estimate may a) Vary from estimates, depending on the actual services performed b) Be guaranteed if the patient satisfies all patient financial responsibilities at the time of registration c) Be lower as price estimates use the highest market price d) Only determine the percentage of the total that the patient is responsible for and not the actual cost - ....ANSWER...A Ambulance services are billed directly to the health plan for a) All pre-admission emergency transports b) Transport deemed medically necessary by the attending paramedic- ambulance crew c) 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 d) The portion of the bill outside of the patient's self-pay - ....ANSWER...C In Chapter 7 straight bankruptcy filling a) The court establishes a creditor payment schedule with the longest outstanding claims paid first b) The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt c) The court vacates all claims against a debtor with the understanding that the debtor may not apply for credit without court supervision d) The court liquidates the debtor's nonexempt property, pays creditors, and begins to pay off the largest claims first. All claims are paid some portions of the amount owed. - ....ANSWER...B The activity which results in the accurate recording of patient bed and level of care assessment, patient transfer and patient discharge status on a real-time basis is known as a) Utilization review b) Case management c) Census management d) Patient through-put - ....ANSWER...B Which of the following is required for participation in Medicaid a) Obtain a supplemental health insurance policy b) Meet income and assets requirements c) Meet a minimum yearly premium d) Be free of chronic conditions - ....ANSWER...B When primary payment is received, the actual reimbursement a) Is compared to the expected reimbursement b) Is recorded by Patient Accounting and the patient's account is the closed c) Is compared to the expected reimbursement, the remaining contractual adjustments are posted, and secondary claims are submitted d) Trigger that the secondary claims can then be prepared. - ....ANSWER...C b) An initial registration record is completed so that the proper coding can be initiated c) The pt then assumes full liability for services unless a third-party payer is notified or the pt applies for financial assistance within the first 48 hours d) The remaining registration processing is initiated either at the bedside or In a registration area - ....ANSWER...A The soft cost of a dissatisfied customer is a) The "cost" of staff providing extra attention in trying to perform service recovery b) The customer passing on info about their negative experience to potential pts or through social media channels c) Potentially negative treatment outcomes leading to expanding length-of-stay d) Lowered quality outcomes for the dissatisfied pt - ....ANSWER...B Concurrent review and discharge planning a) Occurs during service b) Is performed by the health plan during the time of service c) Is a significant part of quality and is performed by the clinical treatment team d) Is performed at discharge with the pt - ....ANSWER...A In a self-insured (or self-funded) plan, the costs of medical care are a) Borne by the employer on a pay-as-you-go basis b) Backed-up by stop-loss insurance against a catastrophic claim c) Mandated by the Affordable Care Act for small businesses unable to obtain commercial coverage d) Created by a combination of employer and employee contributions - ....ANSWER...A In choosing a setting for pt financial discussions, organizations should first and foremost a) Have processes in place to document the discussions b) Assess locations for convenience, professionalism, and comfort c) Respect the pts privacy d) Ensure all staff involved are properly trained and the pt financial education is included in all discussions - ....ANSWER...C All of the following are steps in safeguarding collections EXCEPT a) Placing collections in a lock-box for posting review the next business day b) Posting the payment to the pts account c) Completing balance activities d) Issuing receipts - ....ANSWER...D Which option is a government-sponsored health care program that is financed through taxesand general revenue funds a) Medicaid b) Medicare c) Insurance exchange d) Social security - ....ANSWER...B It is important to calculate reserves to ensure a) Stable financial operations and accurate financial reporting b) Collateral for credit c) Expense coverage in the event of a revenue short fall d) Coverage of B/D write offs and charity care costs - ....ANSWER...A Successful account resolution begins with a) Educating pts on their estimated financial responsibility b) Collecting all deductibles and copayments during the pre-service stage c) Accurate documentation of services d) Pt compliance with the course of treatment - ....ANSWER...B 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 a) A medicare determination appeal b) A payment review c) A medicare supplemental review d) A beneficiary appeal - ....ANSWER...D A portion of the accounts receivable inventory which has NOT qualified for billing includes a) Charitable pledges b) Accounts assigned to a pre-collection agency c) Accounts coded but held within the suspense period d) Accounts created during pre-registration but not activated - ....ANSWER...A Checks received through mail, cash received through mail, and lock box are all examples of a) Highly fraud prone processes b) Payment methods in which the majority of fraud occurs c) Payment methods being phased out for more secure payment method options d) Control points for cash posting - ....ANSWER...D Recognizing that health coverage is complicated and not all pts are able to navigate this terrain, HFMA best practices specify that a) A representative of the health plan be included in the pt financial responsibilities discussion b) The patient accounts staff have someone assigned to research coverage on behalf of pts c) Pts should be given the opportunity to request a pt advocate, family member or other designee to help them In these discussions A recurring/series registration is characterized by a) The creation of one registration record for multiple days of service b) The creation of multiple registrations for multiple services c) The creation of one registration record per diagnosis per visits d) The creation of multiple pt types for one date of service - ....ANSWER...A If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - ...ANSWER...Non-diagnostic service provided on Tuesday through Friday What does a modifier allow a provider to do? - ...ANSWER...Report a specific circumstance that affected a procedure or service without changing the code or its definition IF outpatient diagnostic services are provided within three days of the admission of a Medicare beneficiary to an IPPS (Inpatient Prospective Payment System) hospital, what must happen to these charges - ...ANSWER...They must be billed separately to the part B Carrier what is a recurring or series registration? - ...ANSWER...One registration record is created for multiple days of service What are nonemergency patients who come for service without prior notification to the provider called? - ...ANSWER...Unscheduled patients Which of the following statement apply to the observation patient type? - ...ANSWER...It is used to evaluate the need for an inpatient admission which services are hospice programs required to provide around the clock patient - ...ANSWER...Physician, Nursing, Pharmacy Scheduler instructions are used to prompt the scheduler to do what? - ...ANSWER...Complete the scheduling process correctly based on service requeste The Time needed to prepare the patient before service is the difference between the patients arrival time and which of the following? - ...ANSWER...Procedure time Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: - ...ANSWER...Documentation of the medical necessity for the test What is the advantage of a pre-registration program - ...ANSWER...It reduces processing times at the time of service What date are required to establish a new MPI(Master patient Index) entry - ...ANSWER...The responsible party's full legal name, date of birth, and social security number Which of the following statements is true about third-party payments? - ...ANSWER...The payments are received by the provider from the payer responsible for reimbursing the provider for the patient's covered services. Which provision protects the patient from medical expenses that exceed the pre-set level - ...ANSWER...stop loss what documentation must a primary care physician send to HMO patient to authorize a visit to a specialist for additional testing or care? - ...ANSWER...Referral Under EMTALA (Emergency Medical Treatment and Labor Act) regulations, the provider may not ask about a patient's insurance information if it would delay what? - ...ANSWER...Medical screening and stabilizing treatment Which of the following is a step in the discharge process? - ...ANSWER...Have a case management service complete the discharge plan The hospital has a APC based contract for the payment of outpatient services. Total anticipated charges for the visit are $2,380. The approved APC payment rate is $780. Where will the patients benefit package be applied? - ...ANSWER...To the approved APC payment rate A patient has met the $200 individual deductible and $900 of the $1000 co-insurance responsibility. The co-insurance rate is 20%. The estimated insurance plan responsibility is $1975.00. What amount of coinsurance is due from the patient? - ...ANSWER...$100.00 When is a patient considered to be medically indigent? - ...ANSWER...The patient's outstanding medical bills exceed a defined dollar amount or percentage of assets. What patient assets are considered in the financial assistance application? - ...ANSWER...Sources of readily available funds , vehicles, campers, boats and saving accounts If the patient cannot agree to payment arrangements, What is the next option? - ...ANSWER...Warn the patient that unpaid accounts are placed with collection agencies for further processing What core financial activities are resolved within patient access? - ...ANSWER...scheduling , pre-registration, insurance verification and managed care processing What is an unscheduled direct admission? - ...ANSWER...A patient who arrives at the hospital via ambulance for treatment in the emergency department When is it not appropriate to use observation status? - ...ANSWER...As a substitute for an inpatient admission member co insurance, to a family maximum of $6000 per year excluding the deductible . Five family members are enrolled in this benefit plan. What is the maximum out of pocket expense that that family could incur during the calendar year? - ...ANSWER...$6000 What type of plan restricts benefits for non-emergency care to approve providers only? - ...ANSWER...A POS (point of service )plan What does scheduling allow provider staff to do? - ...ANSWER...Review the appropriateness of the service requested When an adult patient is covered by both his own and his spouse health insurance plan, which of the statements is true? - ...ANSWER...The patients insurance plan is primary Mrs. Jones , a Medicare beneficiary was admitted to the hospital on June 20,2010. As of the admission date, she had only used 8 inpatient days in the current benefit period. If she is not discharge on what date will Mr jones exhaust her full coverage days. - ...ANSWER...August 9, 2010 In order to meet eligibility guidelines for healthcare benefits, Medicaid beneficiaries must fall into a specified need category and meet what other types of requirements - ...ANSWER...Income and assets Fee for service plans pay claims based on a percentage of charges. How are patients out of pocket cost calculated? - ...ANSWER...They are calculated quarterly Indemnity plans usually reimburse what? - ...ANSWER...A certain percentage of charges after patient meets policy's annual deductible. Departments that need to be included in Charge master maintenance include all EXCEPT - ...ANSWER...Quality Assurance Using HIPPA standardized transaction sets allow providers to: - ...ANSWER...Submit a standardized transaction to any of the health plans with which it conducts business. Which of the following is NOT included in the standardized quality measures? - ...ANSWER...Cost of services The ACO investment model will test the use of pre-paid shared savings to: - ...ANSWER...Encourage new ACOs to form in rural and underserved areas. Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons on a monthly fee is known as: - ...ANSWER...HMO Ambulance services are billed directly to the health plan for: - ...ANSWER...Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility. Any provider that has filed a timely cost report may appeal in an adverse final decision received from the Medicare Administrative Contractor (MAC), the appeal may be filed with: - ...ANSWER...The Provider Reimbursement Review Board. For scheduled payments, important revenue cycle activities in the time-of-service stage DO Not include: - ...ANSWER...Obtaining or updating patient and guarantor information Hospital can only convert an inpatient case to observation if: - ...ANSWER...The hospital utilization review committee determines before the patient is discharged and prior to billing that an observation setting would be more appropriate. Hospital need which of the following information sets to assess a patient's financial status? - ...ANSWER...Demographic, Income, Assets and Expenses. HIPAA privacy rules require covered entities to take all, of the following actions EXCEPT: - ...ANSWER...Use only designated software platforms to secure patient date. When Recovery Audit Contractors (RAC) identify improper payments as overpayment. the claims processing contractor must: - ...ANSWER...Send a demand letter to the provider to recover the over payment amount. Which HIPPA transaction set provides electronic processing of 8insurance verification requests and responses? - ...ANSWER...The 270-271 set Across all care settings, if a patient consents to a financial discussion during a medical encounter to expedite discharge, the HFMA best practice is to: - ...ANSWER...Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow. A scheduled inpatient represents an opportunity for the provider to do which of the following? - ...ANSWER...Complete registration and insurance approval before service The Medicare Bundled Payments for Care Initiative (BCP) is designed to: - ...ANSWER...Align incentives between hospitals, physicians, and non-physician providers in-order to better coordinate patient care. To maximize the value derived from customer complaints, all consumer complaints should be: - ...ANSWER...Tracked and shared to improve customer experience