Revenue Cycle Management in Healthcare, Exams of Advanced Education

Download Revenue Cycle Management in Healthcare and more Exams Advanced Education in PDF only on Docsity! CRCR Certification (Certified Revenue Cycle Representative) exam A comprehensive "Compliance Program" is defined as a) Annual legal audit and review for adherence to regulations b) Educating staff on regulations c) Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met d) The development of operational policies that correspond to regulations Correct Answer c) Systematic procedures to ensure that the provisions of regulations imposed by a government 10. Case Management requires that a case manager be assigned a) To patients of any physician requesting case management b) To a select patient group c) To every patient d) To specific cases designated by third party contractual agreement Correct Answer b) To a select patient group 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 a) Identify, compare, and choose providers that offer the desired level of value b) Customize health care with a personally chosen mix of providers c) Negotiate the cost of health plan premiums d) Verify the cost of individual clinicians Correct Answer a) Identify, compare, and choose providers that offer the desired level of value 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 a) MSO b) HMO c) PPO d) GPO Correct Answer b) HMO In a Chapter 7 Straight Bankruptcy filing a) The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt b) The court liquidates the debtor's nonexempt property, pays creditors, and begins to pay off the largest claims first. All claims are paid some portion of the amount owed 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 establishes a creditor payment schedule with the longest outstanding claims paid first Correct Answer a) The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt The core financial activities resolved within patient access include: a) Scheduling, pre-registration, insurance verification and managed care processing b) Scheduling, insurance verification, clinical discharge processing and payment posting of point of service receipts c) Scheduling, registration, charge entry and managed care processing 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 Correct Answer a) Registration staff may routinely contact managed are plans for prior authorizations before the patient is seen by the on-duty physician 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 Correct Answer c) The submitted claim does not have the physicians signature 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 Correct Answer d) The Provider Reimbursement Review Board 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 Correct Answer a) Generation of timely and accurate billing 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 paramedic-ambulance crew Correct Answer c) The portion of the bill outside of the patient's self-pay 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 beneficiary appeal b) A Medicare supplemental review c) A payment review d) A Medicare determination appeal Correct Answer a) A beneficiary appeal The nuanced data resulting from detailed ICD-10 coding allows senior leadership to work with physicians to do all of the following EXCEPT: a) Drive significant improvements in the areas of quality and the patient experience b) Embrace new reimbursement models c) Improve outcomes d) Obtain higher compensation for physicians Correct Answer d) Obtain higher compensation for physicians Duplicate payments occur: a) When providers re-bill claims based on nonpayment from the initial bill submission b) When service departments do not process charges with the organization's suspense days c) When the payer's coordination of benefits is not captured correctly at the time of patient registration d) When there are other healthcare claims in process and the anticipated deductibles and co- insurance amounts still show open but will be met by the in- process claims Correct Answer a) When providers re-bill claims based on nonpayment from the initial bill submission The Affordable Care Act legislated the development of Health Insurance Exchanges, where individuals and small businesses can a) Purchase qualified health benefit plans regardless of insured's health status b) Obtain price estimates for medical services c) Negotiate the price of medical services with providers d) Meet federal mandates for insurance coverage and obtain the corresponding tax deduction Correct Answer a) Purchase qualified health benefit plans regardless of insured's health status The most common resolution methods for credit balances include all the following EXCEPT: a) Designate the overpayment for charity care b) Submit the corrected claim to the payer incorporating credits c) Either send a refund or complete a takeback form as directed by the payer d) Determine the correct primary payer and notify incorrect payer of overpayment Correct Answer a) Designate the overpayment for charity care EFT (electronic funds transfer) is a) An electronic claim submission b) The record of payments in the hospital's accounting system c) An electronic confirmation that a payment is due a) Charity adjustment b) Bad debt adjustment c) Contractual adjustment d) Administrative adjustment Correct Answer b) Bad debt adjustment 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 Correct Answer d) Services and procedures that are custodial in nature All of the following are forms of hospital payment contracting EXCEPT a) Contracted Rebating b) Per Diem Payment c) Fixed Contracting d) Bundled Payment Correct Answer a) Contracted Rebating 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 Correct Answer d) The Medicare Administrative Contractor (MAC) at the end of the hospice cap period With the advent of the Affordable Care Act Health Insurance Marketplaces and the expansion of Medicaid in some states, it is out 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 Correct Answer d) Assist patients in understanding their insurance coverage and their financial obligation 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 Correct Answer d) Transfer from ICU (intensive care unit) to the Medical/Surgical floor is not reflected in the registration system Which of the following is required for participation in Medicaid? a) Meet income and assets requirements b) Meet a minimum yearly premium c) Be free of chronic conditions d) Obtain a health insurance policy Correct Answer a) Meet income and assets requirements HFMA best practices call for patient financial discussions to be reinforced a) By issuing a new invoice to the patient b) By copying the provider's attorney on a written statement of conversation c) By obtaining some type of collateral d) By changing policies to programs Correct Answer b) By copying the provider's attorney on a written statement of conversation A Medicare Part A benefit period begins: a) With admission as an inpatient b) The first day in which an individual has not been a hospital inpatient not in a skilled nursing facility for the previous 60 days c) Upon the day the coverage premium is paid d) Immediately once authorization for treatment is provided by the health plan Correct Answer a) With admission as an inpatient 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 a) Will remain in observation for up to 72 hours after which the patient is admitted as an inpatient b) Will be admitted as an inpatient c) Will be discharged and if needed, designated to a priority one outpatient status d) Will have his/her case reviewed by the attending physician, a consulting physician and the primary care physician and a future course of care will then be determined Correct Answer b) Will be admitted as an inpatient It is important to have high registration quality standards because a) Incomplete registrations will trigger exclusion from Medicare participation b) Incomplete registrations will raise satisfaction scores for the hospital c) Inaccurate registration may cause discharge before full treatment is obtained d) Inaccurate or incomplete patient data will delay payment or cause denials Correct Answer d) Inaccurate or incomplete patient data will delay payment or cause denials Medicare will only pay for tests and services that d) State insurance commissioners Correct Answer b) The Office of the U.S. Inspector General (OIG) 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 Correct Answer c) The opportunity to reduce the corporate compliance failures within the registration process 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. Correct Answer a) Denied by Medicare 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 Correct Answer c) Claims processing 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 Correct Answer b) Encourage new ACOs to form in rural and underserved areas 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 Correct Answer d) That reorganizes a debtor's holdings and instructs creditors to look to the debtor's future earnings for payment 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 Correct Answer c) The service providers that typically participate in the service, e.g., radiologists, pathologists, etc. The important Message from Medicare provides beneficiaries information concerning their: a) Understanding of billing issues and the deductibles and/or co- insurance due for the current visit b) Right to refuse to use lifetime reserve days for the current stay c) Right to appeal a discharge decision if the patient disagrees with the plan d) Obligation to reimburse the hospital for any services not covered by the Medicare program Correct Answer c) Right to appeal a discharge decision if the patient disagrees with the plan All of the following are potential causes of credit balances EXCEPT: a) Duplicate payments b) Primary and secondary payers both paying as primary c) Inaccurate upfront collections based on incorrect liability estimates d) A patient's choice to build up a credit against future medical bills Correct Answer d) A patient's choice to build up a credit against future medical bills Medicare Part B has an annual deductible, and the beneficiary is responsible for a) A co-insurance payment for all Part B covered services b) Physician's office fees c) Tests outside of an inpatient setting d) Prescriptions Correct Answer a) A co-insurance payment for all Part B covered services The importance of medical records being maintained by HIM is that the patient records a) Are the primary source for clinical data required for reimbursement by health plans and liability payers b) Are the strongest evidence and defense in the event of a Medicare audit c) Are evidence used in assessing the quality of care d) Are the evidence cited in quality review Correct Answer a) Are the primary source for clinical data required for reimbursement by health plans and liability payers 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 Correct Answer a) Is admitted from a physician's office on an urgent basis 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 Correct Answer c) Ask the patient if he or she would like to receive information about payment options and supportive financial assistance programs 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 Correct Answer d) Cost of services 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 Correct Answer d) Pre- authorization are obtained 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 Correct Answer a) Clear on policies and consistent in applying the policies 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 Correct Answer b) Patient and guarantor's income, expenses and assets 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" desk Correct Answer c) Final bill is presented for payment 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 Correct Answer b) A standardized form that provides 3rd party payment details to providers 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 Correct Answer c) Documenting the conversation in the medical records 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 Correct Answer d) Reduced internal staffing costs and a reliance on outsourced staff 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) Correct Answer b) Judicial review by a federal district court Business ethics, or organizational ethics represent: c) The arrival time and procedure time d) The patient's preparation instructions Correct Answer a) The results of any and all test Indemnity plans usually reimburse: a) Only for contracted Services b) A claim up to 80% of the charges c) A certain percentage of the charges after the patient meets the policy's annual deductible d) A patient for out-of-pocket charges Correct Answer c) A certain percentage of the charges after the patient meets the policy's annual deductible Because 501(r) regulations focus on identifying potential eligible financial assistants patients hospitals must: a) Capture their experience with such patients to properly budget b) Hold financial conversations with patients as soon as possible c) Build the necessary processes to handle the potentially lengthy payment schedule d) Expedite payment processing of normal accounts receivable to protect cash flow Correct Answer b) Hold financial conversations with patients as soon as possible Which option is a benefit of pre-registering a patient for services a) The patient arrival process is expedited, reducing wait times and delays b) The verification of insurance after completion of the services c) Service departments have the ability to override schedules and block time to reduce testing volume d) The patient receiving multiple calls from the provider Correct Answer a) The patient arrival process is expedited, reducing wait times and delays HIPPA 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 a) The Social Security Administration b) The US department of the Treasury c) The United States department of labor d) The Internal Revenue Service Correct Answer d) The Internal Revenue Service The nightly room charge will be incorrect if the patient's a) Transfer from ICU to the Medical/Surgical floor is not reflected in the registration system. b) Pharmacy orders to the ICU have not been entered into the pharmacy system c) Condition has not been discussed during the shift change report meeting d) Discharge for the next day has not been charted Correct Answer a) Transfer from ICU to the Medical/Surgical floor is not reflected in the registration system. With any remaining open balances, after insurance payments have been posted, the account financial liability is a) Written off as bad debt b) Potentially transferred to the patient c) Sold to a collection agency d) Treated as the cost of doing business Correct Answer b) Potentially transferred to the patient When there is a request for service the scheduling staff member must confirm the patient's unique identification information to: a) Verify the patient's insurance coverage if the patient is a returning customer b) Ensure that she/he accesses the correct information in the historical database c) Confirm that physician orders have been received d) Check if any patient balance due Correct Answer b) Ensure that she/he accesses the correct information in the historical database 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 Correct Answer a) The data collection steps for scheduling and pre-registering a patient 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 c) The resolution of managed care and billing requirements d) The identification of physician fee schedule amounts and the NPI (national provider identifier) numbers Correct Answer a) The accurate identification of the patient's eligibility and benefits 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 Correct Answer d) Revenue codes c) Meet a minimum yearly premium d) Be free of chronic conditions Correct Answer b) Meet income and assets requirements 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. Correct Answer c) Is compared to the expected reimbursement, the remaining contractual adjustments are posted, and secondary claims are submitted Days in A/R is calculated based on the value of a) Total cash received to date b) The time it takes to collect anticipated revenue c) The total accounts receivable on a specific date d) Total anticipated revenue minus expenses Correct Answer c) The total accounts receivable on a specific date All of the following are forms of hospital payment contracting EXCEPT a) Per diem payment b) Bundled Payment c) Fixed Contracting d) Contracted Rebating Correct Answer d) Contracted Rebating The standard claim form used for billing by hospitals, nursing facilities, and other in-Patient services is called the a) UB-04 b) 1500 c) COST REPORT d) REMITTANCE NOTICE Correct Answer a) UB-04 To maximize the value derived from customer complaints, all consumer complaints should be a) Responded to within two business days b) Tracked and shared to improve the customer experience c) Handled by a specially trained "service" team d) Brought immediately to management's attention Correct Answer a) Responded to within two business days The HCAHPS (hospital consumer assessment of healthcare providers and systems) Initiative was launched to a) Gather national date on overall trust in the nation's health care system b) Create a national database on physician quality c) Provide a standardized method for evaluating patient's perspective on hospital care. d) Provide data for building shared savings reimbursement for quality procedures. Correct Answer c) Provide a standardized method for evaluating patient's perspective on hospital care. Health Plan Contracting Departments do all of the following EXCEPT a) Establish a global reimbursement rate to use with all third-party payer b) Review all managed care contracts for accuracy for loading contract terms into the patient accounting system c) Review payment schemes to ensure that the health plan and provider understand how reimbursements must be calculated d) Review contracts to ensure the appeals process for denied claims is clearly specified Correct Answer a) Establish a global reimbursement rate to use with all third-party payer The benefit of Medicare Advantage Plan is a) It is a less costly plan compared to traditional Medicare b) Patients may retain a primary care physician and see another physician for a second opinion at no charge c) Patients generally have their Medicare-coverage healthcare through the plan and do not need to worry about "part" or "part b" benefits d) Patients receive significant discounting on services contracted by the federal government Correct Answer c) Patients generally have their Medicare-coverage healthcare through the plan and do not need to worry about "part" or "part b" benefits Once the EMTALA requirements are satisfied a) Third-party payer info should be collected from the patient and the payer should be notified of the ED visit b) An initial registration record is completed so that the proper coding can be initiated c) The patient then assumes full liability for services unless a third-party payer is notified or the patient 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 Correct Answer a) Third-party payer info should be collected from the patient and the payer should be notified of the ED visit 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 patients or through social media channels c) Potentially negative treatment outcomes leading to expanding length-of-stay d) Lowered quality outcomes for the dissatisfied patient Correct Answer b) The customer passing on info about their negative experience to potential patients or through social media channels 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 Correct Answer a) Charitable pledges 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 Correct Answer d) Control points for cash posting Recognizing that health coverage is complicated and not all patients are able to navigate this terrain, HFMA best practices specify that a) A representative of the health plan be included in the patient financial responsibilities discussion b) The patient accounts staff have someone assigned to research coverage on behalf of patients c) Patients should be given the opportunity to request a patient advocate, family member or other designee to help them in these discussions d) Patient coverage education may need to be provided by the health plan Correct Answer c) Patients should be given the opportunity to request a patient advocate, family member or other designee to help them in these discussions Once the price is estimated in the pre-service stage, a provider's financial best practice is to a) Allow the patient time to compare prices with other providers b) Have another employee double check the price estimate c) Lock-in the prices d) Explain to the patient their financial responsibility and to determine the plan for payment Correct Answer d) Explain to the patient their financial responsibility and to determine the plan for payment Charges as the most appropriate measurement of utilization enables a) Accuracy of expense and cost capture b) Managing of expense budgets c) Effective HIM planning d) Generation of timely and accurate billing Correct Answer a) Accuracy of expense and cost capture 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 a) HMO b) PPO c) MSO d) GPO Correct Answer a) HMO Charges are the basis for a) Third party and regulatory review of resources used b) Evaluating quality c) Separation of fiscal responsibilities between the patient and the health plan d) Demonstrating medical necessity Correct Answer c) Separation of fiscal responsibilities between the patient and the health plan Chapter 13 Bankruptcy, debtor rehabilitation is a court proceeding a) That reorganizes a debtor's holdings and instructs creditors to look to the debtor's future earnings for payment b) That establishes a payment priority order to creditors c) That creates a clear court-supervised payment accountability plan going forward d) That classifies the debtor as eligible for government financial assistance for housing medical treatment and food as debts are paid Correct Answer a) That reorganizes a debtor's holdings and instructs creditors to look to the debtor's future earnings for payment Patient financial communications best practices produce communications that are a) Timely and remind patients of their financial responsibilities b) Consistent, clear and transparent c) Current and report the status of a patients claim d) Timely, comprehensive and specifying next steps Correct Answer b) Consistent, clear and transparent Key performance indicators (KPIs) set standards for accounts receivables (A/R) and a) Establish productivity targets b) Provide a method of measuring the collection and control of A/R c) Provide evidence of financial status d) Make allowance for accurate revenue forecasting Correct Answer b) Provide a method of measuring the collection and control of A/R 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 twelve months Correct Answer c) Send a demand letter to the provider to recover the over payment amount d) The location of the medical treatment provider Correct Answer b) The location of the patient at the time the service is provided HFMA best practices stipulate that a reasonable attempt should be made to have the Financial responsibilities discussion a) As early as possible, before a financial obligation is incurred b) During the registration process c) Before scheduling of services d) No later than the evening of the day of admission Correct Answer a) As early as possible, before a financial obligation is incurred HFMA's patient financial communications best practices specify that patients should be told about the types of services provided and a) An explanation of why a specific service is not provided b) The service providers that typically participate in the service, e.g. Radiologists, pathologists, etc. c) A satisfaction survey regarding clinical service providers d) The price of service to their covering health plan Correct Answer b) The service providers that typically participate in the service, e.g. Radiologists, pathologists, etc. Telemed seeks to improve a patient's health by a) Permitting 2-way real time interactive communication between the patient and the clinical professional b) Using high-compression fiber optics to transmit medical data c) Providing relevant, on-demand consumer medical education d) Providing physician access to the most current medical research Correct Answer a) Permitting 2-way real time interactive communication between the patient and the clinical professional A large number of credit balances are not the result of overpayments but of a) Posting errors in the patient accounting system b) Incorrect claim submissions c) Inadequate staff training d) Banking transaction errors Correct Answer a) Posting errors in the patient accounting system 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 a) Have a patient financial responsibilities kit ready for the patient containing all of the required registration forms and instructions b) Make sure that the attending staff can answer questions and assist in obtaining required patient financial data c) Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow d) Decline such request as finance discussions can disrupt patient care and patient flow Correct Answer c) Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow The office of inspector general (OIG) publishes a compliance work plan a) Monthly b) Quarterly c) Semi-annually d) Annually Correct Answer d) Annually Through what document does a hospital establish compliance standards? Correct Answer Code of Conduct What is the purpose OIG work plan? 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 services 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 day of the admission of a Medicare beneficiary to an IPPS (Inpatient Prospective Payment System) hospital, what must happen to Correct Answer They must be billed separately to the Part B carrier 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 statements 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 on a around-the-clock patient Correct Answer Physician, nursing, and pharmacy Scheduler instructions are used to prompt the scheduler to do what? Correct Answer Complete the scheduling process correctly based on service requested What is an unscheduled direct admission? Correct 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? Correct Answer As a substitute for an inpatient admission Parents 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's privacy notice Which of the following statements applies to self-insured insurance plans? Correct Answer The employer provides a traditional HMO (health maintenance organization) health plan In addition to the member's identification number, what information is records in a 270 transaction? Correct Answer Name What process does a patients' health plan use to retroactively collect payments from liability, automobile, or worker's compensation plans? Correct Answer Subrogation In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? Correct Answer DRG (diagnosis-related groups) rates 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 patient's 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 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 a Medicaid HMO (health maintenance organization) plan? Correct Answer Medicaid-eligible patients are never required to join a Medicaid HMO plan Which of the following is a violation of the EMTALA (Emergency Medical Treatment and Labor Act)? Correct Answer Registration staff members routinely contact managed care plans for prior authorizations before the patients is seen by the on-duty physician 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: $400per family member deductible, to a maximum of $1,200 per year and $2,000 per family member co-insurance, to a family maximum of $6,000 per year, excluding the deductible. Five family members are enrolled in this benefit plan. What is the maximum out-of-pocket expense that the family could incur during the calendar year? Correct Answer $6,000 What type of plan restricts benefits for nonemergency care to approve providers only? Correct Answer A POS (point-of-service) plan 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's health insurance plan, which of the statements is true? Correct Answer The patient's 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 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: 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. 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. 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 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 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 fundamental approach in managing denials is: Correct Answer To analyze the type and sources of denials and consider process changes to eliminate further denials 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 The 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 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 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 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 HFMA best practices call for patient financial discussions to be reinforced: Correct Answer By issuing a new invoice to the patient All of following are steps in safeguarding collections EXCEPT: Correct Answer Placing collections in a lock-box for posting review the next business day The code indication of the disposition of the patient at the conclusion of service is called the: Correct Answer Patient discharge status code HIPPA has adopted Employer Identification Numbers (EINs) to be used in standard transactions to identify the employer of an individual described in a transaction. EINs are created and assigned by: Correct Answer The Internal Revenue Service enrolled group of persons on a monthly fee is known as a: Correct Answer HMO Any provider that has filed a timely cost report may appeal in an adverse final decision received from the Medicare Administrative Contractor (MAC), this 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 Hospitals can only convert an inpatient case to observation if: Correct Answer The hospital utilization review committee determines before the patient is discharged and prior to billing that an observation setting would be more appropriate. HIPPA privacy rules require covered entities to take all of the following actions EXCEPT: Correct Answer Use only designated software platforms to secure patient data. When Recovery Audit Contractors (RAC) identify improper payments as overpayments, the claims processing contractor must: Correct Answer Send a demand letter to the provider to recover the overpayment amount Which HIPPAA transaction set provides electronic processing of insurance verification requests and responses? Correct Answer The 270-271 set. The Medicare Bundled Payments for Care Initiative (BCPI) is designed to:` Correct Answer Align incentives between hospitals, physicians, and non-physician providers in-order to better coordinate patient care. Applying the contracted payment methodology to the total charged yields: Correct Answer An estimated price The importance of medical records being maintained by HIM is that the patient records: Correct Answer Are the primary source for clinical date required for reimbursement by health plans and liability payers In the pre-service stage, 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. 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 violations that impact the revenue cycle include all of the following EXCEPT: Correct Answer Seeking payment options for self-pay A decision on whether a patient should be admitted as an inpatient or become an outpatient observation patient requires medical judgement basement on all of the following EXCEPT: Correct Answer The patient's home care coverage The Affordable Health Care Act legislative 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 four-digit number code established by the National Uniform Committee (NUBC that categorizes/classifies a line in the charge master is known as: Correct Answer Revenue codes During pre-registration, a search for the patient's MPI 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 Claims with dates of service received later than one calendar year beyond the date of service will be Correct Answer Denied by Medicare 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 requires authorization, who is typically responsible for obtaining the authorization: Correct Answer The provider scheduling 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 Outsourcing options should be evaluated as: Correct Answer Any other business service purchase What is an advantage of provider-based clinic? Correct Answer The opportunity to discount professional component services and inflate technical component services without violating Medicare billing rules What is an example of a technical denial? Correct Answer Billing within the timely filing's rules How does the financial counseling process begin? Correct Answer Screen the patient for financial assistance by completing the charity application How does a health plan recover dollars paid for a liability claim from the liability carrier? Correct Answer Subrogation What type of account adjustment results from the patient's inability to pay a self-pay balance? Correct Answer ty adjustment The revenue cycle begins with scheduling a patient for service and ends with what? Correct Answer The archiving of the fully resolved account How does increasing the provision for bad debts affect the financial statement? Correct Answer Reduces gross receivables and increase operation expense for the period A successful Medicare pay-for-performance initiative will likely result in what? Correct Answer Higher payments while covering sicker beneficiaries What are some component of the charge master? Correct Answer Room charges and detailed ancillary charges According to the Department of Health and Human Services guidelines, which of the following is not considered income? Correct Answer Sale of property, house or car Most managed care plans do not permit patient balance billing except for what circumstances? Correct Answer deductible and copayment requirements The situation where neither the patient nor spouse is employed is described to the payer using: Correct Answer A condition code The regulations and requirements for creating accountable care organizations, which allowed providers to begin creating these organization were finalized. Correct Answer 2010 Which services are hospice programs required to provide on an around-the clock basis? Correct Answer Physician, nursing, and pharmacy What is the purpose of the initial step in the outpatient testing scheduling process? Correct Answer Identify the correct patient in the provider's database or add the patient to the database The time needed to prepare the patient before services is the difference between the patient's arrival time and which of the following? Correct Answer Scheduled time. Medicare guidelines require that when a test is ordered for which an LCD or NCD exists, the information provided on the order must include which of the following? Correct Answer Documentation of the medical necessity for the test. What Is an advantage of a preregistration program? Correct Answer It reduces processing times at the time of service What data a required to establish a new MPI? Correct Answer The patients full legal name, date of birth and sex A mother and father both cover their 16-year-old child as a dependent on their health insurance plans, which both follow the birthday rule. The mothers date of birth is 1/19/1968; and the fathers date of birth is 7/19/1967. Whose plan is the primary payer? Correct Answer The mothers plan What is a co-payment? Correct Answer The fixed amount that is due for a specific service? A patient's annual out-of-pocket limitation is $3,000 excluding deductible. To date this calendar year the patient has satisfied the $500 deductible and has paid $2300 in coinsurance to coinsurance to various providers. For the balance of the calendar year, what is the maximum amount of coinsurance the patient will owe? Correct Answer $700.00 What type of plan allows the subscriber to pay lower premium costs in return for a higher deductible? Correct Answer Consumer directed health plan What is a characteristic of a managed care contracting methodology? Correct Answer Prospectively set rates for inpatient and outpatient services Which provision protects the patient from medical expenses that exceed a pre-set level? Correct Answer Stop loss What document must a primary care physician sent to HMO patient to authorize a visit to a specialist for additional testing or care Correct Answer Referral T/F Sending the bill electronically to the health plan is a time-of- service activity Correct Answer False Revenue Cycle Initiatives Correct Answer Healthcare Dollars & Sense:pt financial comm. best practices, best practices for price transparency, medical accounts resolution PFC Best Practices Correct Answer 6 areas:Annual staff training, training program topics, process observation, executive level metrics reporting, technology verification, feedback and response Where individuals and small businesses can compare and purchase qualified health benefit plans Correct Answer Health Insurance Marketplace/Health Insurance exchange Medical Debt Task Force Correct Answer developed a best practice workflow that builds off of HFMA's previous patient friendly billingwork and spansthe patient-centric revenue cycle. The following statements describe best practices established by the Medical Debt Task Force Correct Answer Educate patients, coordinate to avoid duplicate patient contacts, be consistent in key aspects of account resolution, follow best practices for communication Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Correct Answer standardized method for evaluating patients' perspective on hospital care Hard Costs Correct Answer loss of future revenue Soft Costs Correct Answer customer's passing on information about their negative experience to potential patients or through social media channels Post Acute Services Correct Answer include skilled nursing , home health, durable medical equipment, hospice, and assisted living Skilled Nursing Facility (SNF) Correct Answer institution (skilled nursing home/rehabilitation center) engaged in provided skilled nursing care for injured/disabled/sick persons Durable Medical Equipment (DME) Correct Answer Medical equipment that is prescribed by a doctor for use in the home Home Health Agency (HHA) Correct Answer public agency or private organization Level 1 Modifier Correct Answer usually provide info about performance of a procedures/apply to CPT/consist of 2 numbers Level 2 Modifiers Correct Answer used for OPPS/provide addtl detail ab out an anatomical location or about a procedure or service/apply to HCPCS codes/consist of either 2 letters or a 1 letter & 1 number Correct Coding Initiative(CCI) E Correct Answer purpose is to ensure that the most comprehensive groups of codes, rather than the component parts, are billed. THe program consists of edits that are implemented within providers' claim processing systems Ethics Violations Correct Answer Financial misconduct/Overcharging/Theft of property/ Falsifying records to boos reimbursement/miscoding claims Affordable Care Act (ACA) Correct Answer includes provisions to improve the quality of care/reform the healthcare delivery system/encourage pricing transparency and modernized financing systems/address the issues of waste,fraud, and abuse Accountable Care Organization (ACO) Correct Answer delivery system of physicians, hospitals, and other healthcare providers, who work collaboratively to manage and coordinate the care of a patient population. Includes appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients Bundled Payments for Care Improvement (BPCI) Correct Answer initiative was developed by the Center for Medicare and Medicaid Innovation to link payments for multiple services beneficiaries receive during an episode of care Balance Sheet Correct Answer statement is a summary of the organizations wealth as of the date of the statement. it represents the summary of the organizations assets, liabilities and accumulated excesses from operations less any accumulated losses. Income Statement Correct Answer ties directly to the balance sheet and is the summary of the organizations revenues and expenses and any excess or loss from operations Cash Flow Statement Correct Answer this statement is the summary of how cash was used and where it was obtained Accrual Accounting Correct Answer revenue is recorded when it is earned to permit the alignment of revenue with the associated expenses. Cash Accounting Correct Answer records revenue when payment is received Non Acute: Skilled Nursing Correct Answer patients are admitted into skilled nursing units or facilities (SNF)when they no longer meet criteria for acute care, but still need an inpatient level of skilled nursing care or rehabilititation services Bipartisan Budget Act Correct Answer 2018 provided a permanent exceptions process for the physical therapy and speech language pathology and the separate occupational therapy caps Local Coverage Determinations Correct Answer guidelines that Medicare established to determine which diagnoses, signs, or symptoms are payable. 270 Health Care Eligibility Benefit Inquiry Correct Answer 270 transaction is the outbound inquiry from the provider to the health plan. Includes the IDnumber/DOB of insured party Medicare Correct Answer government-sponsored program which is financed through taxes and general revenue funds Medicaid Correct Answer federally aided, state operated program to provide health and long term care coverage for low-income individuals or families Tricare Correct Answer healthcare program of the United States Departmentof Defense Military Health System Commercial Indemnity Plans Correct Answer plans cover almost all services without authorization requirements 837-I or UB 04 paper form Correct Answer hospital inpatient and outpatient services are submitted to medicare and medicare advantage plans electronically using these forms 837-P orCMS 1500 paper form Correct Answer Physician servicesare submitted electronically using these forms Medicaid programs cover: Correct Answer inpatient/outpatient hospital services/physician,midwife and nurse practioner services/nursing home services for persons aged 21+/pregnancy related servicess/family planning services and supplies/lab and XR services Tricare Prime Correct Answer HMOtype program Tricare Standard and Extra Correct Answer fee-for-service plan available to all non-active duty beneficiaries throughout the US Tricare for Life Correct Answer supplement to the medicare program and only available to individuals who are also enrolled in Medicare Part A and Part B benefits HMO's Correct Answer supply the beneficiary with a directory of physicians from which to choose a PCP/physician coordinates the beneficiary's care (benef. must contact their PCPto be referred to a specialist or obtain prior auth for non emergency hospital services Preferred Provider Organization (PPO) Correct Answer where a third party payer contracts with a group of medical care providers who furnish services at lower than usual fees in return for guarantees of a certain volume of patients Exclusive Provider Organization (EPO) Correct Answer form of PPOin which a very select group of providers is chosen to provide benefits to one or a very limited number of entities, usually a single employer Point of Service Plan (POS) Correct Answer healthcare insurance plan that allows the member to select providers either in network or out of network; beneficiaries are enrolled in an HMObut have the option to go outside of the network for an addtl cosst Managed care health plans use prior auths and utilization management review to determine care is medically necessary Correct Answer includes pre cert/pre auth, referrals, notification, Site-of-Service Limitations, Case Management, Discharge Planning Constructing a Price Estimate Correct Answer Verify/Identify/Obtain total charges Emergency Medical Treatment and Labor Act (EMTALA) Correct Answer requires hospitalsto provide a medical screening examination and nay needed stabilizing treatment to every person present at an EDand requesting medical eval or treatment EMTALA prohibits Correct Answer inquiries about health plan or liability payer (TPL)information if the inquiry will delay examination or treatment Emergency Department (ED) Correct Answer patients initially triaged by medical personnel, where quick reg record is generated to specifically allow order entry. After triage patient is either placed in a bed or may return to waiting room Master Patient Index (MPI) Correct Answer data collection includes patients full legal name, SSN, and/or DOB Newborn Admissions Correct Answer Mother's reg info is used to generate the newborn registration record; once baby is named then the newborn record will be separated from mother's record Resource Management Correct Answer allows more timely and accurate billing and collecting, which improves net collections and cash flow/ ensures that bills do not have to be held for late charges / decreases research efforts generally as questions related to duplicate charges, charge codes, and so forth are reduced Charge Master Correct Answer a list of services/procedures, room accommodations, supplies, drugs/biologics, and/or radiopharmaceuticals that may be billed to a hospital inpatient or outpatient and includes the charge specific data needed for claim submission Charge Description Master (CDM) Correct Answer unique identifier number assigned to a given line item in the chargemaster Department Number Correct Answer number assigned to a particular department denotes the revenue generating area Current Procedural Terminology (CPT) Codes Correct Answer codes that describe services, procedures, and drugs Revenue Codes Correct Answer 4 digit number code established by the National Uniform Billing (NUBC)that categorizes/classifies a line item in the chargemaster General Ledger (GL) Number Correct Answer a number used for accounting purposes that directs the revenue to the appropriate department Level 1 HCPCS Codes Correct Answer approved american medical associations cpt-4 codes/all cpt-4 codes are included within the hcpcps code listing/these 5 digit hcpcs codes are numeric Level IIHCPCS Codes Correct Answer CMS developedcodes for classifying supplies and non-physician services such as DME,ambulance services, medical and surgical supplies and drugs/ level IIbegin with single letter followed by 4 numeric digits Level III HCPCS Codes Correct Answer contain codes assigned and maintained by medicare admin contractors these codes begin with a letter W-Z followed by 4 numeric digits/ these codes are not common and are used basically to describe new procedures not yet developed in level I and II Health Information Management (HIM) Correct Answer responsible for the management of all patient medical records HIM Required Correct Answer plays role in ensuring the accuracy of the codes documented on the claim Activities of HIM Correct Answer ensuring the security and completion of electronic and hardcopy medical records, transcribing physician dictation including histories and physicals operative reports and discharge summaries/ analyzing information necessary for decision support/performing chart analysis/reviewing the medical record, assigning diagnosis and procedure codes and classifying data for reimbursement Hard-Coded Correct Answer when the code is assigned via the chargemaster / typically only utilized for procedure coding Soft-Coded Correct Answer when HIM coder is responsible for reviewing and/or assigning the diagnosis or procedure codes UB-04 Correct Answer standard HOSPITAL claim form/ contains 81 form locators and is used by hospitals, hospice, rural health clinics, SNF for submitting claims CMS 1500 Correct Answer standard PROFESSIONAL service claim form/ contains 33 major items, subdivided into a total of 55 detailed items and is used by professional service providers (physic., allied health prof, certified registered nurse anesthetists, home health agencies, medical equipment suppliers)for submitting claims for services to health plans Condition Codes Correct Answer used by provider to describe conditions or events that apply to the period being billed on the claim Occurrence Codes Correct Answer provides addtl info pertaining to the period being billed on the claim Occurrence Span Code Correct Answer used for an event that spans a period of time Value Codes Correct Answer related dollar or unit amounts represent data of a monetary nature that are necessary for the processing of a claim Claim Edits Correct Answer rules developed to verify the accuracy and completeness of claims based on each health plan's policies Council for Affordable Quality Healthcare (CAQH) Correct Answer multi-stakeholder collaboration of more than 130 organizations working to develop operating rules to simplify healthcare admin transactions/ their goal is to ensure that detailed, real-time response becomes the standard for claims-related healthcare transactions Level 1 of ProviderAppeals Correct Answer redetermination by a medicare administrative contractor (MAC) Level 2 of Provider Appeals Correct Answer Reconsideration by a Qualified Independent Contractor (QIC) Level 3 Provider Appeals Correct Answer Administrative Law Judge (ALJ) Hearing or REview by office of medicare hearing and appeals LEvel 4 Provider Appeals Correct Answer REview by the Medicare Appeals Council Level 5 Provider Appeals Correct Answer Judicial review in US District ourt Clean Claim Correct Answer claim for reimbursement submitted to a third-party payer that has all information and documentation required for the payer to make a decision on payment or denial Electronic Worklist Correct Answer functionality that identifies claims that remain unpaid a specific number of days from the initial billing date Medicare Common Working File (CWF) Correct Answer host of databases that houses all beneficiary claim history and entitlement information. Lien Correct Answer claim against real or personal property that secures payment of a debt or performance fo some other acct Security Interest Correct Answer when personal property is used as collateral Health &Human Services (HHS) Income definition Correct Answer money wages and salaries, net receipts from self employment, regular payments from social security, unemployment compensation, workers comp, veterans payments, public assistance and alimony and child support Affordable Care Act(ACA) Correct Answer lays out requirements for:community health needs assessments, policies related to financial assistance, emergency medical care, billing and collections activities Extraordinary Collections Actions (ECA) Correct Answer legal actions/selling the debt to a third party/reporting adverse information to credit bureaus or agencies, deferring or denying medically necessary care because of non payment for previously provided care that is covered by FAP Consumer Credit Protection Act Correct Answer major components Truth in Lending act/restrictions on garnishment, fair credit reporting acct, fair debt collection practices Act Truth in Lending Act Correct Answer establishes disclosure rules for consumer credit sales and consumer loans Restrictions on Garnishment Correct Answer legal proceeding whereby money or property due or belonging to a debtor but in the possession of another is applied to the payment of the debt of the plaintiff Fair Credit Reporting Act Correct Answer affects those who issue or use reports on consumers in connection with the approval of credit and protects consumer's rights and has exact standard that limits the use of consumer credit reports Fair Debt Collection Practices Act Correct Answer applies only to third-party collection agencies that collect consumer debt. 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 Which of the following is required for participation in Medicaid Correct Answer Meet Income and Assets Requirements In choosing a setting for patient financial discussions, organizations should first and foremost Correct Answer Respect the patients privacy A nightly room charge will be incorrect if the patient's Correct 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 Correct 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: Correct Answer Charitable pledges What is required for the UB-04/837-I, used by Rural Health Clinics to generate payment from Medicare? Correct Answer Revenue codes This directive was developed to promote and ensure healthcare quality and value and also to protect consumers and workers in EXCEPT: Correct Answer Judicial review by a federal district court Under EMTALA (Emergency Medical Treatment and Labor Act) regulations, the providermay not ask about a patient's insurance information if it would delay what? Correct Answer Medical screening and stabilizing treatment 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 Key performance indicators (KPIs) set standards for accounts receivables (A/R) and Correct Answer Provide a method of measuring the collection and control of A/R he patient discharge process begins when Correct Answer The physician writes the discharge orders The nightly room charge will be incorrect if the patient's Correct Answer Transfer from ICU to the Medical/Surgical floor is not reflected in the registration system. The soft cost of a dissatisfied customer is Correct 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 Correct Answer The opportunity to reduce the corporate compliance failures within the registration process It is important to have high registration quality standards because Correct Answer Inaccurate or incomplete patient data will delay payment or cause denials Telemed seeks to improve a patient's health by Correct 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 Correct 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 Correct 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 Correct 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 Correct Answer UB-04 Charges are the basis for Correct Answer Separation of fiscal responsibilities between the patient and the health plan All of the following are forms of hospital payment contracting EXCEPT Correct Answer Contracted Rebating The most common resolution methods for credit balances include all of the following EXCEPT: Correct Answer Designate the overpayment for charity care Ambulance services are billed directly to the health plan for Correct 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 Correct 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 Correct Answer Medicare and Medicaid payments The Correct Coding Initiative Program consists of Correct 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 Correct Answer The actual physician reimbursement Which department supports/collaborates with the revenue cycle? Correct Answer Information Technology Medicare Part B has an annual deductible and the beneficiary is responsible for Correct Answer a co-insurance payment for all Part B covered services The two types of claims denial appeals are Correct Answer Beneficiary and Provider Which of the following is a violation of the EMTALA (Emergency Medical Treatment and Labor Act?) Correct Answer Registration staff members routinely contact managed care plans for prior authorizations before the patient is seen by the on duty physician "Hard-coded" is the term used to refer to Correct 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 Correct Answer Providers pay pennies on each dollar collected Which of the following is usually covered on a Conditions of Admission form Correct Answer Release of information The 501(r) regulations require not-for-profit providers (501(c)(3) organizations) to do which of the following activities. Correct 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 Correct 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 Correct Answer The electronic submission of claims using electronic transfers There are unique billing requirements based on Correct Answer The provider type The unscheduled "direct" admission represents a patient who: Correct Answer Is admitted from a physician's office on an urgent basis In resolving medical accounts, a law firm may be used as: Correct Answer A substitute for a collection agency The legal authority to request and analyze provider claim documentation to ensure that Correct Answer The Office of the U.S. Inspector General (OIG) The office of inspector general (OIG) publishes a compliance work plan Correct Answer Annually Room and bed charges are typically posted Correct Answer From the midnight census All of the following information should be reviewed as part of schedule finalization EXCEPT: Correct Answer The results of any and all test Revenue cycle activities occurring at the point-of-service include all of the following EXCEPT: Correct Answer Providing charges to the third-party payer as they are incurred HFMA's patient financial communications best practices specify that pts should be told about the Correct Answer The service providers that typically participate in the service, e.g. radiologists ,pathologists, etc. The core financial activities resolved within patient access include: Correct Answer Scheduling, pre-registration, insurance verification and managed care processing A decision on whether a patient should be admitted as an inpatient or become about patient observation patient requires medical judgments based on all of the following EXCEPT Correct Answer The patient's home care coverage Which option is a benefit of pre-registering a patient for services Correct Answer The patient arrival process is expedited, reducing wait times and delays Days in A/R is calculated based on the value of Correct Answer The total accounts receivable on a specific date Case Management requires that a case manager be assigned Correct Answer To a select patient group Which of the following is required for participation in Medicaid? Correct Answer Meet income and assets requirements All of the following are steps in safeguarding collections EXCEPT Correct Answer Issuing receipts The Electronic Remittance Advice (ERA) data set is : Correct Answer A standardized form that provides third party payment details to providers All of the following are conditions that disqualify a procedure or service from being paid for by Medicare EXCEPT Correct Answer Services and procedures that are custodial in nature Medicare beneficiaries remain in the same "benefit period" Correct Answer Until the beneficiary is "hospitalization and/or skilled nursing facility-free" for 60 consecutive days It is important to calculate reserves to ensure Correct Answer Stable financial operations and accurate financial reporting A claim is denied for the following reasons, EXCEPT: Correct Answer The submitted claim does not have the physicians signature HFMA best practices call for patient financial discussions to be reinforced Correct Answer By changing policies to programs