HFMA CRCR Exam Questions and Answers: Understanding Healthcare Revenue Cycle Management, Exams of Nursing

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Through what document does a hospital establish compliance standards? - correct answer ✅code of conduct What is the purpose OIG work plant? - correct answer ✅Identify Acceptable compliance programs in various provider setting If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - correct answer ✅Non-diagnostic service provided on Tuesday through Friday What does a modifier allow a provider to do? - correct 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 - correct answer ✅They must be billed separately to the part B Carrier

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what is a recurring or series registration? - correct 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? - correct answer ✅Unscheduled patients Which of the following statement apply to the observation patient type? - correct answer ✅It is used to evaluate the need for an inpatient admission which services are hospice programs required to provide around the clock patient - correct answer ✅Physician, Nursing, Pharmacy Scheduler instructions are used to prompt the scheduler to do what? - correct 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? - correct answer ✅Procedure time

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Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: - correct answer ✅Documentation of the medical necessity for the test What is the advantage of a pre-registration program - correct answer ✅It reduces processing times at the time of service What date are required to establish a new MPI(Master patient Index) entry - correct 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? - correct 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 - correct answer ✅stop loss

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what documentation must a primary care physician send to HMO patient to authorize a visit to a specialist for additional testing or care? - correct 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? - correct answer ✅Medical screening and stabilizing treatment Which of the following is a step in the discharge process? - correct 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? - correct 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? - correct answer ✅$100.

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When is a patient considered to be medically indigent? - correct 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? - correct 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? - correct answer ✅Warn the patient that unpaid accounts are placed with collection agencies for further processing What core financial activities are resolved within patient access? - correct answer ✅scheduling , pre-registration, insurance verification and managed care processing What is an unscheduled direct admission? - correct answer ✅A patient who arrives at the hospital via ambulance for treatment in the emergency department

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When is it not appropriate to use observation status? - correct answer ✅As a substitute for an inpatient admission Patients who require periodic skilled nursing or therapeutic care receive services from what type of program? - correct answer ✅Home health agency Every patient who is new to the healthcare provider must be offered what? - correct answer ✅A printed copy of the provider privacy notice Which of the following statements apples to self insured insurance plans? - correct answer ✅The employer provides a traditional HMO health plan In addition to the member's identification number, what information is recorded in a 270 transaction - correct answer ✅Name What process does a patient's health plan use to retroactively collect payments from liability automobile or worker's compensation plan? - correct answer ✅Subrogation

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In what type of payment methodology is a lump sum of bundled payment negotiated between the payer and some or all providers? - correct answer ✅DRG/Case rate What Restriction does a managed care plan place on locations that must be used if the plan is to pay for the service provided? - correct answer ✅Site of service limitation Which of the following statements applies to private rooms? - correct answer ✅If the medical necessity for a private room is documented in the chart. The patients insurance will be billed for the differential Which of the following is true about screening a beneficiary of possible MSP(Medicare secondary payer) situations? - correct answer ✅It is necessary to ask the patient each of the MSP questions Which of the following is not true of Medicare Advantage Plans? - correct answer ✅A patient must have both Medicare Part A and B benefits to be eligible for a Medicare Advantage plan

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Which of the following is a valid reason for a payer to deny a claim? - correct answer ✅Failure to complete authorization Which of the following statements is NOT a possible consequence of selecting the wrong patient in the MPI(master patient index) - correct answer ✅Claim is paid in full Which of the following statements is true of a Medicare Advantage Plan? - correct answer ✅This plan supplements Part A and Part B benefits Which is the following is not a characteristic of Medicaid HMO plan? - correct answer ✅Medicaid-eligible patients are never required to join a Medicaid HMO plan Which of the following is violation of the EMTALA? - correct answer ✅Registration staff members routinely contact managed care plans for prior authorizations before the patients is seen by the on duty physician

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Which of the following statements is true of the important message from Medicare notification requirements? - correct answer ✅Notification can be issued no earlier than 7 days before admission and no more than 2 days before discharge. What is the self pay balance after insurance - correct answer ✅The portion of the adjudicated claim that is due from the patient Which of the following options is an alternative to valid long term payment plans - correct answer ✅Bank loans The patient has the following benefit plan $400 per family member deductible, to a maximum of $1200 per year and $2000 per family member co insurance, to a family maximum of $6000 per year excluding the deductible. Five family members are enrolled in this benefit plan. What is the maximum out of pocket expense that that family could incur during the calendar year? - correct answer ✅$ What type of plan restricts benefits for non-emergency care to approve providers only? - correct answer ✅A POS (point of service )plan

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What does scheduling allow provider staff to do? - correct 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? - correct 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. - correct 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 - correct answer ✅Income and assets Fee for service plans pay claims based on a percentage of charges. How are patients out of pocket cost calculated? - correct answer ✅They are calculated quarterly

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Indemnity plans usually reimburse what? - correct 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 - correct answer ✅Quality Assurance Using HIPPA standardized transaction sets allow providers to: - correct 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? - correct answer ✅Cost of services The ACO investment model will test the use of pre-paid shared savings to: - correct answer ✅Encourage new ACOs to form in rural and underserved areas.

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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: - correct answer ✅HMO Ambulance services are billed directly to the health plan for: - correct answer ✅Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility. 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: - correct answer ✅The Provider Reimbursement Review Board. For scheduled payments, important revenue cycle activities in the time-of- service stage DO Not include: - correct answer ✅Obtaining or updating patient and guarantor information Hospital can only convert an inpatient case to observation if: - correct answer ✅The hospital utilization review committee determines before the

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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? - correct answer ✅Demographic, Income, Assets and Expenses. HIPAA privacy rules require covered entities to take all, of the following actions EXCEPT: - correct 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: - correct 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? - correct 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: -

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correct 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? - correct answer ✅Complete registration and insurance approval before service The Medicare Bundled Payments for Care Initiative (BCP) is designed to: - correct 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: - correct answer ✅Tracked and shared to improve customer experience The soft cost of a dissatisfied customer is: - correct answer ✅The customer passing on information about their negative experience to potential patients or through social media channels.

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Applying the contracted payment methodology to the total charges yields: - correct answer ✅An estimate price The importance of medical records maintained by HIM is that the patient records: - correct answer ✅Are the primary source for clinical data required for reimbursement by health plans and liability payers Important Revenue Cycle Activities in the pre-service stage include: - correct answer ✅Obtaining or updating patient and guarantor information In the pre-service stage, the cost of the schedule services is identified and the patient's health plan and benefits are used to calculate: - correct answer ✅The amount the patient may be expected to pay after insurance. The disadvantage of outsourcing includes all, of the following Except - correct answer ✅Reduces internal staffing costs and a reliance on outsourced staff.

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Marinating routine contact with health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of who: - correct answer ✅Case Management A claim is denied for the following reasons EXCEPT: - correct answer ✅The submitted claim does not have the physician signature All Hospitals are required to establish a written financial assistance policy that applies to: - correct answer ✅All emergency and medically necessary care Examples of ethics violation that impact the revenue cycle include all of the following EXCEPT: - correct answer ✅Seeking payment options for self-pay Verbal orders from a physician for a service(s) are: - correct answer ✅Acceptable if given to "qualified" staff as defined in a hospitals policies and procedures

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Medicare has established guidelines called Local Coverage Determination (LCD) and National Coverage Determination (NCD) that establish: - correct answer ✅What serviced or healthcare items are covered under Medicare? A decision on whether a patient should be admitted as an inpatient or become an outpatient observation patient requires medical judgement based on all of the following EXCEPT: - correct answer ✅The patient's home care coverage What is the first step of the daily cash reconciliation process? - correct answer ✅Obtaining cash, check, credit card and debit card payment from that day The healthcare industry is vulnerable to compliance issues, in large part due to the complexity of the statutes and regulations pertaining to: - correct answer ✅Medicare and Medicaid payments The correct coding initiative program consist of: - correct answer ✅Edits that are implemented within provider's claim processing system

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The Affordable Health Care Act legislated the development of Health Insurance Exchange, where individuals and small businesses can: - correct answer ✅Purchase health benefits plans regardless of insured's health status Before classifying and subsequently writing off an account to financial assistance or bad debit, the hospital must establish policy define appropriate criteria, implement procedures for identifying accounts and: - correct answer ✅Monitor compliance The Electronic Remittance Advice (ERA) data sets are: - correct answer ✅A standardized for that provides 3rd party payment details to providers The first and most critical step in registering a patient, whether scheduled or unscheduled is: - correct answer ✅Verifying the patient's identification The standard claim form used for the billing by hospitals, nursing facilities, and other inpatient services is called the: - correct answer ✅UB-

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A four-digit number code established by the National Uniform Billing Committee (NUBC) that categorizes/classifies a line in the charge master is known as: - correct answer ✅Revenue codes Internal controls addressing coding and reimbursement charges are put in place to guard against: - correct answer ✅Compliance fraud by "upcoding" The 501(R) regulations require non-for-profit providers (501) ©(3) organizations to do which of the following activities: - correct answer ✅Complete a community needs assessment and develop a discount program for patient's balances after insurance payment During pre-registration, a search for the patient's MRI number is initiated using which of the following data sets: - correct answer ✅Patient's full legal name and date of birth or the patient's Social Security number To maximize the value derived from customer complaints, all consumer complaints should be: - correct answer ✅Tracked and shared to improve the customer experience

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The Business ethics, or organizational ethics represent: - correct answer ✅The principles and standards by which organizations operate Providers are advised that it is best to establish patient financial responsibility and assistance policies and make sure they are followed internally and by: - correct answer ✅Third-party payers The advantage to using a third-part, collection agency includes all of the following EXCEPT: - correct answer ✅Providers pay pennies on each dollar collected. Local Coverage Determination (LCD) and National Coverage Determinations (NCD) are Medicare established guidelines used to determine: - correct answer ✅Which diagnosis, signs, or symptoms are reimbursable Claims with the dates of service received later than one calendar year beyond the date of service will be: - correct answer ✅Denied by Medicare

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in the pre-service stage, the requested service is screened for medical necessity, health plan coverage and benefits are verified and: - correct answer ✅Pre-authorization are obtained For scheduled patients, important revenue cycle activities in the time-of - service stage DO NOT include: - correct answer ✅Final bill is presented for payment If a medical service authorization, who is typically responsible for obtaining the authorization: - correct answer ✅The provider scheduling Concurrent review and discharge planning - correct answer ✅Occurs during service The fundamental approach in managing denials is: - correct answer ✅To analyze the type and sources of denials and consider process changes to eliminate further denials

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The first thing a health plan does when processing a claim is: - correct answer ✅Check if the patient is a health plan beneficiary and what is the coverage Outsourcing options should be evaluated as - correct answer ✅Any other business service purchase Insurance verification results in which of the following: - correct answer ✅The accurate identification of the patient's eligibility and benefits EMTLA and HFMA best practices specify that in an Emergency Department setting: - correct answer ✅No patient financial discussions should occur before a patient is screened and stabilized he HCCAHPS (Hospital Consumer Assessment of Healthcare Provider's and Systems) initiative was launched to: - correct answer ✅Provide a standardized method for evaluation patients' perspective on hospital care All of the following are potential causes of credit balances EXCEPT: - correct answer ✅A patient's choice to build up a credit against future medical bills

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Medicare will only pay for tests and services that: - correct answer ✅Can be demonstrated as necessary This 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: - correct answer ✅Joint Commission for Acceleration of Healthcare Organizations (JCAHO) safety standards It is important to calculate reserves to ensure: - correct answer ✅A stable financial operations and accurate financial reporting An advantage of a pre-registration program in - correct answer ✅The opportunity to reduce processing times at the time of service To be eligible for Medicaid, an individual must: - correct answer ✅Meet income and asset requirements

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The patient discharge process begins when: - correct answer ✅The physician writes the order Appropriate training for patient financial counseling staff must cover all of the following EXCEPT: - correct answer ✅Documenting the conversation in the medical records Patients should be informed that costs presented in a price estimation may: - correct answer ✅Only determine the percentage of the total that the patients is responsible for and not the actual cost. Any healthcare insurance plan that providers or insures comprehensive health maintenance and services for an enrolled group of persons based on a monthly fee is known as a - correct answer ✅HMO Chapter 11 Bankruptcy permits a debtor to: - correct answer ✅Work out a court-supervised plan with creditors

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A portion of the accounts receivable inventory which has NOT qualified for billing includes: - correct answer ✅Accounts created during pre-registration but not activated Overall aggregate payments made to a hospice are subject to a computed "cap amount" calculated by: - correct answer ✅The Medicare Administrative Contractor (MAC) at the end of the hospice cap period The ICD-10 code set and CPT/HCPCS code sets combined provide: - correct answer ✅The specificity and coding accuracy needed to support reimbursement claims Charges, as the most appropriate measurement of utilization, enables: - correct answer ✅Generation of timely and accurate billing Days in A/R calculated based on the value of: - correct answer ✅The total account receivable on a specific date Medicare benefits provide coverage for: - correct answer ✅Inpatient hospital services, skilled nursing care. And home health care

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