Revenue Cycle Management in Healthcare, Exams of Nursing

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CRCR CERTIFICATION EXAM 2024/2025 WITH 100% ACCURATE SOLUTIONS Overall aggregate payments made to a hospice are subject to a computed "cap amount" calculated by - Precise Answer ✔✔The Medicare Administrative Contractor (MAC) at the end of the hospice cap period Which of the following is required for participation in Medicaid - Precise Answer ✔✔Meet Income and Assets Requirements In choosing a setting for patient financial discussions, organizations should first and foremost - Precise Answer ✔✔Respect the patients privacy A nightly room charge will be incorrect if the patient's - Precise Answer ✔✔Transfer from ICU (intensive care unit) to the Medical/Surgical floor is not reflected in the registration system The Affordable Care Act legislated the development of Health Insurance Exchanges, where individuals and small businesses can - Precise Answer ✔✔Purchase qualified health benefit plans regardless of insured's health status A portion of the accounts receivable inventory which has NOT qualified for billing includes: - Precise Answer ✔✔Charitable pledges What is required for the UB-04/837-I, used by Rural Health Clinics to generate payment from Medicare? - Precise Answer ✔✔Revenue codes 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 - Precise Answer ✔✔Patient bill of rights 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 - Precise Answer ✔✔Case management Which statement is an EMTALA (Emergency Medical Treatment and Active Labor Act) violation? - Precise Answer ✔✔Registration staff may routinely contact managed are plans for prior authorizations before the patient is seen by the on-duty physician HIPAA had adopted Employer Identification Numbers (EIN) to be used in standard transactions to identify the employer of an individual described in a transaction EIN's are assigned by - Precise Answer ✔✔The Internal Revenue Service Checks received through mail, cash received through mail, and lock box are all examples of - Precise Answer ✔✔Control points for cash posting Ambulance services are billed directly to the health plan for - Precise Answer ✔✔Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility Key performance indicators (KPIs) set standards for accounts receivables (A/R) and - Precise Answer ✔✔Provide a method of measuring the collection and control of A/R he patient discharge process begins when - Precise Answer ✔✔The physician writes the discharge orders The nightly room charge will be incorrect if the patient's - Precise Answer ✔✔Transfer from ICU to the Medical/Surgical floor is not reflected in the registration system. The soft cost of a dissatisfied customer is - Precise Answer ✔✔The customer passing on info about their negative experience to potential pts or through social media channels An advantage of a pre-registration program is - Precise Answer ✔✔The opportunity to reduce the corporate compliance failures within the registration process It is important to have high registration quality standards because - Precise Answer ✔✔Inaccurate or incomplete patient data will delay payment or cause denials Telemed seeks to improve a patient's health by - Precise Answer ✔✔Permitting 2-way real time interactive communication between the patient and the clinical professional Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons based on a monthly fee is known as a - Precise Answer ✔✔HMO Identifying the patient, in the MPI, creating the registration record, completing medical necessity screening, determining insurance eligibility and benefits resolving managed care, requirements and completing financial education/resolution are all - Precise Answer ✔✔The data collection steps for scheduling and pre-registering a patient Medicare Part B has an annual deductible, and the beneficiary is responsible for - Precise Answer ✔✔A co-insurance payment for all Part B covered services The standard claim form used for billing by hospitals, nursing facilities, and other inpatient - Precise Answer ✔✔UB-04 Charges are the basis for - Precise Answer ✔✔Separation of fiscal responsibilities between the patient and the health plan All of the following are forms of hospital payment contracting EXCEPT - Precise Answer ✔✔Contracted Rebating The most common resolution methods for credit balances include all of the following EXCEPT: - Precise Answer ✔✔Designate the overpayment for charity care Ambulance services are billed directly to the health plan for - Precise Answer ✔✔The portion of the bill outside of the patient's self-pay A claim for reimbursement submitted to a third-party payer that has all the information and documentation required for the payer to make a decision on it is known as - Precise Answer ✔✔A clean claim The healthcare industry is vulnerable to compliance issues, in large part due to the complexity of the statutes and regulations pertaining to - Precise Answer ✔✔Medicare and Medicaid payments The Correct Coding Initiative Program consists of - Precise Answer ✔✔Edits that are implemented within providers' claim processing systems To provide a patient with information that is meaningful to them, all of the following factors must be included EXCEPT - Precise Answer ✔✔The actual physician reimbursement HFMA best practices indicate that the technology evaluation is conducted to - Precise Answer ✔✔Continually align technology with processes rather than technology dictating processes Scheduler instructions are used to prompt the scheduler to - Precise Answer ✔✔Complete the scheduling process correctly based on service requested When billing Rural Health Clinic services on a UB-04/837-I, specific CPT codes are collapsed into a single revenue code (520 or 521). Although codes are collapsed into a single revenue code, it is still important to list the appropriate CPT codes as part - Precise Answer ✔✔These codes will be used to determine medical necessity and useful in determining what happened during the encounter What is likely to occur if credit balances are not identified separately from debit balances in accounts receivable? - Precise Answer ✔✔The accounts receivable level would be understated The process of verifying health insurance coverage, identifying contract terms, and obtaining total charges is known as - Precise Answer ✔✔insurance verification and reimbursable charges Unless the patient encounter is an emergency, it is more efficient and effective to - Precise Answer ✔✔Collect all information after the patient has been discharged Applying the contracted payment amount to the amount of total charges yields - Precise Answer ✔✔A pricing agreement "Hard-coded" is the term used to refer to - Precise Answer ✔✔Codes for services, procedures, and drugs automatically assigned by the charge master The advantages to using a third-party collection agency include all of the following EXCEPT - Precise Answer ✔✔Providers pay pennies on each dollar collected Which of the following is usually covered on a Conditions of Admission form - Precise Answer ✔✔Release of information The 501(r) regulations require not-for-profit providers (501(c)(3) organizations) to do which of the following activities. - Precise Answer ✔✔Complete a community needs assessment and develop a discount program for patient balances after insurance payment To be eligible for Medicaid, an individual must - Precise Answer ✔✔meet income and asset requirements Eliminating mail time and reducing data entry time, electronically monitoring the receipt of claims and online claim adjudication, more prompt payment are all benefits achieved by - Precise Answer ✔✔The electronic submission of claims using electronic transfers There are unique billing requirements based on - Precise Answer ✔✔The provider type The unscheduled "direct" admission represents a patient who: - Precise Answer ✔✔Is admitted from a physician's office on an urgent basis In resolving medical accounts, a law firm may be used as: - Precise Answer ✔✔A substitute for a collection agency The legal authority to request and analyze provider claim documentation to ensure that - Precise Answer ✔✔The Office of the U.S. Inspector General (OIG) The office of inspector general (OIG) publishes a compliance work plan - Precise Answer ✔✔Annually Room and bed charges are typically posted - Precise Answer ✔✔From the midnight census All of the following information should be reviewed as part of schedule finalization EXCEPT: - Precise Answer ✔✔The results of any and all test Revenue cycle activities occurring at the point-of-service include all of the following EXCEPT: - Precise Answer ✔✔Providing charges to the third-party payer as they are incurred Patients should be informed that costs presented in a price estimate may - Precise Answer ✔✔Vary from estimates, depending on the actual services performed The nuanced data resulting from detailed ICD-10 coding allows senior leadership to work with physicians to do all of the following EXCEPT: - Precise Answer ✔✔Obtain higher compensation for physicians Charges as the most appropriate measurement of utilization enables - Precise Answer ✔✔Accuracy of expense and cost capture Once the EMTALA requirements are satisfied - Precise Answer ✔✔The remaining registration processing is initiated at the bedside or in a registration area 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: - Precise Answer ✔✔Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow In Chapter 7 straight bankruptcy filling - Precise Answer ✔✔The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt Chapter 13 Bankruptcy, debtor rehabilitation is a court proceeding - Precise Answer ✔✔That reorganizes a debtor's holdings and instructs creditors to look to the debtors' future earnings for payment This concept encompasses all activities required to send a request for payment to a third-party health plan for payment of benefits - Precise Answer ✔✔Claims processing The importance of Medical records being maintained by HIM is that the patient records: - Precise Answer ✔✔Are the primary source for clinical data required for reimbursement When there is a request for service, the scheduling staff member must confirm the patient's unique identification information to - Precise Answer ✔✔Ensure that she/he accesses the correct information in the historical database 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: - Precise Answer ✔✔Case Management Key Performance Indicators (KPIs) set standards for accounts receivables (A/R) and - Precise Answer ✔✔Provide a method of measuring the collection and control of A/R With any remaining open balances, after insurance payments have been posted, the account financial liability is - Precise Answer ✔✔Potentially transferred to the patient Pricing transparency is defined as readily available information on the price of healthcare services, that together with other information, help define the value of those services and enable consumers to - Precise Answer ✔✔Identify, compare, and choose providers that offer the desired level of value All of the following are potential causes of credit balances EXCEPT - Precise Answer ✔✔A patient's choice to build up a credit against future medical bills A comprehensive "Compliance Program" is defined as - Precise Answer ✔✔Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met An originating site is - Precise Answer ✔✔The location of the patient at the time the service is provided Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) are Medicare established guideline(s) used to determine: - Precise Answer ✔✔Which diagnoses, signs, or symptoms are reimbursable If further treatment can only be provided in a hospital setting, the patient's condition cannot be evaluated and/or treated within 24 hours, or if there is not an anticipation of improvement in the patient's condition with 24 hours, the patient - Precise Answer ✔✔Will be admitted as an inpatient appropriate criteria, implement - Precise Answer ✔✔Monitor compliance Medicare will only pay for tests and services that - Precise Answer ✔✔Medicare determines are "reasonable and necessary" The physician who wrote the order for an inpatient service and is in charge of the patients - Precise Answer ✔✔The attending physician When primary payment is received, the actual reimbursement - Precise Answer ✔✔Is compared to the expected reimbursement, the remaining contractual adjustments are posted, and secondary claims are submitted The ICD-10 codes set and CPT/HCPCS code sets combines provide - Precise Answer ✔✔The specificity and coding needed to support reimbursement claims In a self-insured (or self-funded) plan, the costs of medical care are - Precise Answer ✔✔Borne by the employer on a pay-as-you-go basis Indemnity plans usually reimburse: - Precise Answer ✔✔A certain percentage of the charges after the patient meets the policy's annual deductible The first and most critical step in registering a patient, whether scheduled or unscheduled, is - Precise Answer ✔✔Verifying the patient's identification When Recovery Audit Contractors (RAC) identify improper payments as over payments, the - Precise Answer ✔✔Send a demand letter to the provider to recover the over payment amount Across all care settings, if a patient consents to a financial discussion during a medical encounter - Precise Answer ✔✔Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow Overall aggregate payments made to a hospice are subject to a computed "cap amount" calculated by: - Precise Answer ✔✔Each state's Medicaid plan Medicare patients are NOT required to produce a physician order to receive which of these services - Precise Answer ✔✔Screening Mammography, flu vaccine or pneumonia vaccine EFT (electronic funds transfer) is - Precise Answer ✔✔An electronic transfer of funds from payer to payee The importance of medical records being maintained by HIM is that the patient records - Precise Answer ✔✔Are the primary source for clinical data required for reimbursement by health plans and liability payers Days in A/R is calculated based on the value of: - Precise Answer ✔✔The time it takes to collect anticipated revenue To maximize the value derived from customer complaints, all consumer complaints should be - Precise Answer ✔✔Responded to within two business days A scheduled inpatient represents an opportunity for the provider to do which of the following? - Precise Answer ✔✔Complete registration and insurance approval before service In the pre-service stage, the requested service is screened for medical necessity, health - Precise Answer ✔✔Pre-authorization are obtained Hospitals need which of the following information sets to assess a patient's financial status: - Precise Answer ✔✔Patient and guarantor's income, expenses and assets Patients are contacting hospitals to proactively inquire about costs and fees prior to - Precise Answer ✔✔The fact that charge master lists the total charge, not net charges that reflect charges after a payer's contractual adjustment HIPAA had adopted Employer Identification Numbers (EIN) to be used in standard transactions to identify the employer of an individual Answer ✔✔The service providers that typically participate in the service, e.g., radiologists, pathologists, etc. Successful account resolution begins with - Precise Answer ✔✔Collecting all deductibles and copayments during the pre-service stage Recognizing that health coverage is complicated and not all patients are able to navigate this terrain, HFMA best practices specify that - Precise Answer ✔✔Patients should be given the opportunity to request a patient advocate, family member, or other designee to help them in these discussions In the balance resolution process, providers should: - Precise Answer ✔✔Ask the patient if he or she would like to receive information about payment options and supportive financial assistance programs Business ethics, or organizational ethics represent: - Precise Answer ✔✔The principles and standards by which organizations operate Which option is a government-sponsored health care program that is financed through taxes and general revenue funds - Precise Answer ✔✔Medicare Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons based on; a monthly fee is known as a - Precise Answer ✔✔HMO In a Chapter 7 Straight Bankruptcy filing - Precise Answer ✔✔The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt When there is a request for service the scheduling staff member must confirm the patient's - Precise Answer ✔✔Ensure that she/he accesses the correct information in the historical database 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 - Precise Answer ✔✔Revenue codes Appropriate training for patient financial counseling staff must cover all of the following EXCEPT: - Precise Answer ✔✔Documenting the conversation in the medical records The ACO investment model will test the use of pre-paid shared savings to - Precise Answer ✔✔Encourage new ACOs to form in rural and underserved areas When recovery audit contractors (RAC) identify improper payments as over payments the claims processing contractor must - Precise Answer ✔✔Send a demand letter to the provider to recover the over payment amount The purpose of the ACA mandated Community Health Needs Assessment is - Precise Answer ✔✔To identify significant health needs, prioritize those needs and identify resources to address them A balance sheet is - Precise Answer ✔✔A statement of assets, liabilities, and capital for an organization at a specified point in time Hospitals can only convert an inpatient case to observation if the hospital utilization review committee determines this status before the patient is discharged and - Precise Answer ✔✔Prior to billing, that an observation setting will be more appropriate During pre-registration, a search for the patients MPI number is initiated using which of the following data sets? - Precise Answer ✔✔Patient's full legal name and date of birth or the patient's Social Security number Because case managers document the clinical reasons for treatment, they are - Precise Answer ✔✔A good resource when developing written appeals of denials The Truth in Lending Act establishes - Precise Answer ✔✔Disclosure rules for consumer credit sales and consumer loans What is Continuum of Care? - Precise Answer ✔✔The coordination and linkage of resources needed to avoid the duplication of services and the facilitation of a seamless movement among care settings Which of the following is NOT included in the Standardized Quality Measures? - Precise Answer ✔✔ Account Receivable (A/R) Aging reports - Precise Answer ✔✔Divide accounts receivable into 30, 60, 90 ,120 days past due categories Patients expect value for their healthcare dollar, including greater transparency of - Precise Answer ✔✔Quality and price information The impact of denials on the revenue cycle includes all of the following EXCEPT - Precise Answer ✔✔Patient outcomes Examples of ethics violations that impact the revenue cycle include all of the following EXCEPT - Precise Answer ✔✔Seeking payment options for patient self-pay Scheduled procedures routinely include - Precise Answer ✔✔Patient preparation instructions ICD-10-CM and ICD-10-PCS codes sets are modifications of - Precise Answer ✔✔The International ICD-10 codes as developed by the WHO (World Health Organization) The result of accurate census balancing on a daily basis is - Precise Answer ✔✔The correct recording of room charges All of the following are steps in verifying insurance EXCEPT - Precise Answer ✔✔The patient signing the statement of financial responsibility Health Information Management (HIM) is responsible for - Precise Answer ✔✔All patient medical records This form contains major items, subdivided into a total of 55 detailed items, and is used by professional service providers and not hospitals for submitting claims for services to health plans this form is called - Precise Answer ✔✔The 1500 Which of the following is NOT a factor in self-pay follow-up? - Precise Answer ✔✔The type of patient (inpatient, out-patient) The Office of Inspector General (OIG) was created - Precise Answer ✔✔Detect and prevent fraud, waste, and abuse - Precise Answer ✔✔