Revenue Cycle Management in Healthcare, Exams of Nursing

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CURRENTLY TESTING SOLUTIONS OF CRCR FINAL EXAM QUESTIONS WITH ACTUAL CORRECT DETAILED ANSWERS Overall aggregate payments made to a hospice are subject to a computed "cap amount" calculated by - ANSWER-The Medicare Administrative Contractor (MAC) at the end of the hospice cap period Which of the following is required for participation in Medicaid - ANSWER-Meet Income and Assets Requirements In choosing a setting for patient financial discussions, organizations should first and foremost - ANSWER- Respect the patients privacy A nightly room charge will be incorrect if the patient's - 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 - 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: - ANSWER- Charitable pledges What is required for the UB-04/837-I, used by Rural Health Clinics to generate payment from Medicare? - 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 - 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 - ANSWER-Case management Which statement is an EMTALA (Emergency Medical Treatment and Active Labor Act) violation? - 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 - ANSWER-The Internal Revenue Service Checks received through mail, cash received through mail, and lock box are all examples of - ANSWER- Control points for cash posting What are some core elements if a board-approved financial assistance policy? - ANSWER-Eligibility, application process, and nonpayment collection activities A recurring/series registration is characterized by - ANSWER-The creation of one registration record for multiple days of service With the advent of the Affordable Care Act Health Insurance Marketplaces and the expansion of Medicaid in some states, it is more important than ever for hospitals to - ANSWER-Assist patients in understanding their insurance coverage and their financial obligation The purpose of a financial report is to: - ANSWER-Present financial information to decision makers The standard claim form used for billing by hospitals, nursing facilities, and other inpatient - ANSWER- UB-04 Charges are the basis for - ANSWER-Separation of fiscal responsibilities between the patient and the health plan All of the following are forms of hospital payment contracting EXCEPT - ANSWER-Contracted Rebating The most common resolution methods for credit balances include all of the following EXCEPT: - ANSWER- Designate the overpayment for charity care Ambulance services are billed directly to the health plan for - 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 - 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 - ANSWER-Medicare and Medicaid payments The Correct Coding Initiative Program consists of - 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 - ANSWER-The actual physician reimbursement Which department supports/collaborates with the revenue cycle? - ANSWER-Information Technology Medicare Part B has an annual deductible and the beneficiary is responsible for - ANSWER-a co- insurance payment for all Part B covered services The two types of claims denial appeals are - ANSWER-Beneficiary and Provider Which of the following is a violation of the EMTALA (Emergency Medical Treatment and Labor Act?) - ANSWER-Registration staff members routinely contact managed care plans for prior authorizations before the patient is seen by the on duty physician Rural Health Clinics (RHC) personnel can provide services in all of the following locations, EXCEPT - ANSWER-Providing inpatient services in the RHC The patient discharge process begins when - ANSWER-The physician writes the discharge order Departments that need to be included in charge master maintenance include all of the following EXCEPT - ANSWER-Quality Assurance The first thing a health plan does when processing a claim is - ANSWER-Check if the patient is a health plan beneficiary and what is the coverage Vital to accurate calculations of a patient's self-pay amount is - ANSWER- The most accurate way to validate patient information is to - ANSWER-require clinical staff to verify information at each treatment encounter In order for Regulation Z to apply, a hospital must - ANSWER- All of the following are minimum requirements for new patients with no MPI number EXCEPT - ANSWER- Address A typical routine patient financial discussion would include - ANSWER-Explaining the benefits identified through verifying the patients insurance Components of financial education include informing the patient of the hospital's financial policies, assessing the patient's ability to pay and - ANSWER-Reviewing payment alternatives with the patient so appropriate resolution of the health care financial obligation is achieved HFMA best practices indicate that the technology evaluation is conducted to - ANSWER-Continually align technology with processes rather than technology dictating processes Scheduler instructions are used to prompt the scheduler to - 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 - 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? - 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 - ANSWER-insurance verification and reimbursable charges Unless the patient encounter is an emergency, it is more efficient and effective to - ANSWER-Collect all information after the patient has been discharged Applying the contracted payment amount to the amount of total charges yields - ANSWER-A pricing agreement "Hard-coded" is the term used to refer to - 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 - ANSWER- Providers pay pennies on each dollar collected Which of the following is usually covered on a Conditions of Admission form - ANSWER-Release of information A claim is denied for the following reasons, EXCEPT: - ANSWER-The submitted claim does not have the physicians signature HFMA best practices call for patient financial discussions to be reinforced - ANSWER-By changing policies to programs Patients should be informed that costs presented in a price estimate may - 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: - ANSWER-Obtain higher compensation for physicians Charges as the most appropriate measurement of utilization enables - ANSWER-Accuracy of expense and cost capture Once the EMTALA requirements are satisfied - 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: - ANSWER-Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow In Chapter 7 straight bankruptcy filling - 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 - 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 - ANSWER-Claims processing The importance of Medical records being maintained by HIM is that the patient records: - 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 - 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: - ANSWER-Case Management Key Performance Indicators (KPIs) set standards for accounts receivables (A/R) and - 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 - 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 - ANSWER-Identify, compare, and choose providers that offer the desired level of value All of the following are potential causes of credit balances EXCEPT - ANSWER-A patient's choice to build up a credit against future medical bills A comprehensive "Compliance Program" is defined as - ANSWER-Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met An originating site is - 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: - 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 - ANSWER-Will be admitted as an inpatient The benefit of Medicare Advantage Plan is - ANSWER-Patients generally have their Medicare-coverage healthcare through the plan and do not need to worry about "part a" or "part b" benefits The process of creating the pre-registration record ensures - ANSWER-Accurate billing Claims with dates of service received later than one calendar year beyond the date of service, will be - ANSWER-Denied by Medicare A portion of the accounts receivable inventory which has NOT qualified for billing includes - ANSWER- Charitable pledges The standard claim form used for billing by hospitals, nursing facilities, and other in-patient - ANSWER- UB-04 Once the price is estimated in the pre-service stage, a provider's financial best practice is to - ANSWER- Explain to the patient their financial responsibility and to determine the plan for payment Internal controls addressing coding and reimbursement changes are put in place to guard against - ANSWER-Compliance fraud by upcoding Health Plan Contracting Departments do all of the following EXCEPT - ANSWER-Establish a global reimbursement rate to use with all third-party payer For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions: - ANSWER-Should take place between the patient or guarantor and properly trained provider representatives What type of account adjustment results from the patient's unwillingness to pay a self-pay balance? - ANSWER-Bad debt adjustment Most major health plans including Medicare and Medicaid, offer - ANSWER-Electronic and/or web portal verification Patients are contacting hospitals to proactively inquire about costs and fees prior to - 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 described in a transaction EIN's are assigned by - ANSWER-The Internal Revenue Service The HCAHPS (hospital consumer assessment of healthcare providers and systems) initiative - ANSWER- Provide a standardized method for evaluating patient's perspective on hospital care. A large number of credit balances are not the result of overpayments but of - ANSWER-Posting errors in the patient accounting system A Medicare Part A benefit period begins: - ANSWER-With admission as an inpatient Chapter 13 Bankruptcy, debtor rehabilitation, is a court proceeding - ANSWER-That reorganizes a debtor's holdings and instructs creditors to look to the debtor's future earnings for payment Which of the following in NOT included in the Standardized Quality Measures - ANSWER-Cost of services The disadvantages of outsourcing include all of the following EXCEPT: - ANSWER-Reduced internal staffing costs and a reliance on outsourced staff Improving the overall patient experience requires revenue cycle leadership and staff to simultaneously be: - ANSWER-Clear on policies and consistent in applying the policies Because 501(r) regulations focus on identifying potential eligible financial assistants patients hospitals must: - ANSWER-Hold financial conversations with patients as soon as possible Which of the following is NOT contained in a collection agency agreement? - ANSWER-A mutual hold- harmless clause HFMA best practices stipulate that a reasonable attempt should be made to have the financial - ANSWER-As early as possible, before a financial obligation is incurred Recognizing that health coverage is complicated and not all pts are able to navigate this terrain, HFMA best practices specify that - ANSWER-Patients should be given the opportunity to request a patient advocate, family member or other designee to help them In these discussions For scheduled patients, important revenue cycle activities In the Time of Service stage DO NOT INCLUDE: - ANSWER-Final bill is presented for payment HFMA's patient financial communication best practices specify that patients should be told about the types of services provided and - ANSWER-The service providers that typically participate in the service, e.g., radiologists, pathologists, etc. Successful account resolution begins with - 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 - 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: - 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: - 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 - 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 - ANSWER- HMO In a Chapter 7 Straight Bankruptcy filing - 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 - 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 - ANSWER-Revenue codes Appropriate training for patient financial counseling staff must cover all of the following EXCEPT: - ANSWER-Documenting the conversation in the medical records The ACO investment model will test the use of pre-paid shared savings to - ANSWER-Encourage new ACOs to form in rural and underserved areas When recovery audit contractors (RAC) identify improper payments as over payments the claims processing contractor must - 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 - ANSWER-To identify significant health needs, prioritize those needs and identify resources to address them A balance sheet is - 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 - 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? - ANSWER-Patient's full legal name and date of birth or the patient's Social Security number Scheduled procedures routinely include - ANSWER-Patient preparation instructions ICD-10-CM and ICD-10-PCS codes sets are modifications of - 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 - ANSWER-The correct recording of room charges All of the following are steps in verifying insurance EXCEPT - ANSWER-The patient signing the statement of financial responsibility Health Information Management (HIM) is responsible for - 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 - ANSWER-The 1500 Which of the following is NOT a factor in self-pay follow-up? - ANSWER-The type of patient (inpatient, out-patient) The Office of Inspector General (OIG) was created - ANSWER-Detect and prevent fraud, waste, and abuse - ANSWER- The disadvantages of outsourcing include all of the following EXCEPT: a) The impact of customer service or patient relations b) The impact of loss of direct control of accounts receivable services c) Increased costs due to vendor ineffectiveness d) Reduced internal staffing costs and a reliance on outsourced staff - ANSWER-D The Medicare fee-for service appeal process for both beneficiaries and providers includes all of the following levels EXCEPT: a) Medical necessity review by an independent physician's panel b) Judicial review by a federal district court c) Redetermination by the company that handles claims for Medicare d) Review by the Medicare Appeals Council (Appeals Council) - ANSWER-B Business ethics, or organizational ethics represent: a) The principles and standards by which organizations operate b) Regulations that must be followed by law c) Definitions of appropriate customer service d) The code of acceptable conduct - ANSWER-A A portion of the accounts receivable inventory which has NOT qualified for billing includes: a) Charitable pledges b) Accounts created during pre-registration but not activated c) Accounts coded but held within the suspense period d) Accounts assigned to a pre-collection agency - ANSWER-A Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) are Medicare established guideline(s) used to determine: a) Medicare and Medicaid provider eligibility b) Medicare outpatient reimbursement rates c) Which diagnoses, signs, or symptoms are reimbursable d) What Medicare reimburses and what should be referred to Medicaid - ANSWER-C Days in A/R is calculated based on the value of: a) The total accounts receivable on a specific date b) Total anticipated revenue minus expenses c) The time it takes to collect anticipated revenue d) Total cash received to date - ANSWER-C Patients are contacting hospitals to proactively inquire about costs and fees prior to agreeing to service. The problem for hospitals in providing such information is: a) That hospitals don't want to establish a price without knowing if the patient has insurance and how much reimbursement can be expected b) The fact that charge master lists the total charge, not net charges that reflect charges after a payer's contractual adjustment c) That hospitals don't want to be put in the position of "guaranteeing" price without having room for additional charges that may arise in the course of treatment d) Their reluctance to share proprietary information - ANSWER-B 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) Make sure that the attending staff can answer questions and assist in obtaining required patient financial data 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 d) Scheduling, pre-registration, registration, medical necessity screening and patient refunds - ANSWER-A Which of the following is NOT contained in a collection agency agreement? a) A clear understanding that the provider retains ownership of any outsourced activities b) Specific language as to who will pay legal fees, if needed c) An annual renewal clause d) A mutual hold-harmless clause - ANSWER-D Maintaining routine contact with the health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of: a) Patient Accounts b) Managed Care Contract Staff c) HIM staff d) Case Management - ANSWER-D What is required for the UB-04/837-I, used by Rural Health Clinics to generate payment from Medicare? a) Revenue codes b) Correct Part A and B procedural codes c) The CMS 1500 Part B attachment d) Medical necessity documentation - ANSWER-A Before classifying and subsequently writing off an account to financial assistance or bad debt, the hospital must establish policy, define appropriate criteria, implement procedures for identifying and processing accounts: a) Monitor compliance b) Have the account triaged for any partial payment possibilities c) Assist in arranging for a commercial bank loan d) Obtain the patients income tax statements from the prior 2 years - ANSWER-A For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions: a) Are optional b) Should take place between the patient or guarantor and properly trained provider representatives c) May take place between the patient and discharge planning d) Are focused on verifying required third-party payer information - ANSWER-B The purpose of a financial report is to: a) Provide a public record, if reqluested b) Present financial information to decision makers c) Prepare tax documents d) Monitor expenses - ANSWER-B Which statement is an EMTALA (Emergency Medical Treatment and Active Labor Act) violation? a) Registration staff may routinely contact managed are plans for prior authorizations before the patient is seen by the on-duty physician b) Initial registration activities may occur so long as these activities do not delay treatment or suggest that treatment with not be provided to uninsured individuals c) Co-payments may be collected at the time of service once the medical screening and stabilization activities are completed d) Signage must be posted where it can be easily seen and read by patients - ANSWER-A A claim is denied for the following reasons, EXCEPT: a) The health plan cannot identify the subscriber b) The frequency of service was outside the coverage timeline c) The submitted claim does not have the physicians signature d) The subscriber was not enrolled at the time of service - ANSWER-C Any provider that has filed a timely cost report may appeal an adverse final decision received from the Medicare Administrative Contractor (MAC). This appeal may be filed with a) A court appointed federal mediator b) The Department of Health and Human Services Provider Relations Division c) The Office of the Inspector General d) The Provider Reimbursement Review Board - ANSWER-D 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 - ANSWER-A 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 d) An electronic transfer of funds from payer to payee - ANSWER-D Revenue cycle activities occurring at the point-of-service include all of the following EXCEPT: a) The monitoring of charges b) The provision of case management and discharge planning services c) Providing charges to the third-party payer as they are incurred d) The generation of charges - ANSWER-C Medicare beneficiaries remain in the same "benefit period" a) Up to hospitalization discharge b) Until the beneficiary is "hospitalization and/or skilled nursing facility-free" for 60 consecutive days c) Each calendar year d) Up to 60 days - ANSWER-B Key Performance Indicators (KPIs) set standards for accounts receivables (A/R) and a) Provide evidence of financial status b) Provide a method of measuring the collection and control of A/R c) Establish productivity targets d) Make allowance for accurate revenue forecasting - ANSWER-B Recognizing that health coverage is complicated and not all patients are able to navigate this terrain, HFMA best practices specify that a) The patient accounts staff have someone assigned to research coverage on behalf of patients b) Patients should be given the opportunity to request a patient advocate, family member, or other designee to help them in these discussions c) Patient coverage education may need to be provided by the health plan d) A representative of the health plan be included in the patient financial responsibilities discussion - ANSWER-B When there is a request for service, the scheduling staff member must confirm the patient's unique identification information to a) Check if there is any patient balance due b) Verify the patient's insurance coverage if the patient is a returning customer c) Confirm that physician orders have been received d) Ensure that she/he accesses the correct information in the historical database - ANSWER-D Once the price is estimated in the pre-service stage, a provider's financial best practice is to a) Explain to the patient their financial responsibility and to determine the plan for payment b) Allow the patient time to compare prices with other providers c) Lock-in the prices d) Have another employee double check the price estimate - ANSWER-A What type of account adjustment results from the patient's unwillingness to pay a self- pay balance? a) Charity adjustment b) Bad debt adjustment c) Contractual adjustment d) Administrative adjustment - ANSWER-B All of the following are conditions that disqualify a procedure or service from being paid for by Medicare EXCEPT a) Medically unnecessary b) Not delivered in a Medicare licensed care setting c) Offered in an outpatient setting d) Services and procedures that are custodial in nature - ANSWER-D All of the following are forms of hospital payment contracting EXCEPT a) 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 - ANSWER-B 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 - ANSWER-D Medicare will only pay for tests and services that a) Constitute appropriate treatment and are fairly priced b) Have solid documentation c) Can be demonstrated as necessary d) Medicare determines are "reasonable and necessary" - ANSWER-D Room and bed charges are typically posted a) From case management reports generated for contracted payers b) Through the case management daily resource report c) At the end of each business day d) From the midnight census - ANSWER-D The process of creating the pre=registration record ensures a) Ability to pursue extraordinary collection activities b) Early and productive communication with a third-party payer c) Accurate billing d) That access staff will have the compete and valid information needed to finalize any remaining pre-access activities - ANSWER-C Once the EMTALA requirements are satisfied a) Third-party payer information should be collected from the patient and the payer should be notified of the ED visit b) The patient then assumes full liability for services unless a third- party is notified or the patient applies for financial assistance with the first 48 hours c) The remaining registration processing is initiated at the bedside or in a registration area d) An initial registration records is completed so that the proper coding can be initiated - ANSWER-C This directive was developed to promote and ensure healthcare quality and value and also to protect consumers and workers in the healthcare system. This directive is called a) Payer quality monitoring b) Medicare patient and staff safety standards c) Joint Commission for Accreditation of Healthcare Organizations (JCAHO) safety d) Patient bill of rights - ANSWER-D A scheduled inpatient represents an opportunity for the provider to do which of the following? a) Refer the patient to another location with the health system b) Comply with EMTALA (Emergency Medical Treatment and Labor Act) requirements before service c) Complete registration and insurance approval before service d) Register the patient after he or she is placed in a bed on that service unit. - ANSWER-C The first and most critical step in registering a patient, whether scheduled or unscheduled, is a) Having the patient initial the HIPAA privacy statement b) Verifying insurance to activate the patient medical record c) Verifying the patient's identification d) Check the schedule for treatment availability - ANSWER-C The legal authority to request and analyze provider clam documentation to ensure that IPPS services were reasonable and necessary is given to a) Recovery Audit Contractors (RAC) b) The Office of the U.S. Inspector General (OIG) c) All health plans d) State insurance commissioners - ANSWER-B An advantage of a pre-registration program is a) The opportunity to reduce processing times at the time of service 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 - ANSWER-D 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) Physicians office fees c) Tests outside of an inpatient setting d) Prescriptions - ANSWER-A 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 - ANSWER-A A decision on whether a patient should be admitted as an inpatient or become an outpatient observation patient requires medical judgments based on all of the following EXCEPT a) The patient's home care coverage b) Current medical needs c) The likelihood of an adverse event occurring to the patient d) The patient's medical history - ANSWER-A Medicare has established guidelines called the Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) that establish a) Provider and physician reimbursement for specific diagnoses and tests b) Prospective Medicare patient financial responsibilities for a given diagnosis c) Reasonable and customary prices for services in a given area d) What services or healthcare items are covered under Medicare - ANSWER-D What are some core elements if a board-approved financial assistance policy? a) Payment requirements, staffing hours, and admission policies b) Case management, payment methods, and discharge policies c) Deposit requirements, pre-registration calling hours, and charity care policy d) Eligibility, application process, and nonpayment collection activities - ANSWER-D The ICD-10 codes set and CPT/HCPCS code sets combines provide a) Pricing floors for services b) The financial data required for activity-based costing c) Patients an overview of services covered by their health insurance plan d) The specificity and coding needed to support reimbursement claims - ANSWER-D A recurring/series registration is characterized by a) A creation of multiple registrations for multiple services b) The creation of one registration record for multiple days of service c) The creation of multiple patient types for one date of service d) The creation of one registration record per diagnosis per visit - ANSWER-B Under EMTALA (Emergency Medical Treatment and Labor Act) regulations, the provider may not ask about a patient's insurance information if it would delay what? a) Complete course of treatment b) Medical screening and stabilizing treatment c) Admission to observation status d) Transfer to another facility - ANSWER-B In resolving medical accounts, a law firm may be used as: a) An independent auditor of a financial assistance policy b) Legal counsel to patients regarding financing options c) An independent broker of patient financial assistance from banks d) A substitute for a collection agency - ANSWER-D The unscheduled "direct" admission represents a patient who: a) Is admitted from a physician's office on an urgent basis b) Arrives at the hospital via ambulance for treatment in the emergency room c) Is an ambulatory patient who collapses in the hospital lobby d) Arrives on the medical helicopter for trauma services - ANSWER-A In the balance resolution process, providers should: a) Stress to the patient that serious consequences may result from refusal to pay b) Remind the patient of their legal responsibility to pay the balance due c) Ask the patient if he or she would like to receive information about payment options and supportive financial assistance programs d) Tag the patients record for possible financial assistance for bad debt - ANSWER-C Which of the following in NOT included in the Standardized Quality Measures 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 - ANSWER-C 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 - ANSWER-B 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 - ANSWER-A 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 - ANSWER-D 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 - ANSWER-A 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 - ANSWER-B 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 - ANSWER-B Identifying the patient, in the MPI, creating the registration record, completing medical necessity screening, determining insurance eligibility and benefits resolving managed care, requirements and completing financial education/resolution are all a) The data collection steps for scheduling and pre-registering a patient b) Registration steps that must be completed before any medical services are provided c) The steps mandated for billing Medicare Part A d) The process of closing an account - ANSWER-A Insurance verification results in which of the following a) The accurate identification of the patient's eligibility and benefits b) The consistent formatting of the patient's name and identification number The resolution of managed care and billing requirements The identification of physician fee schedule amounts and the NPI (national provider identifier) numbers - ANSWER-A A four digit number code established by the National Uniform Billing Committee (NUBC) that categorizes/classifies a line item in the charge master is known as a) HCPCs codes b) ICD-10 Procedural codes c) CPT codes d) Revenue codes - ANSWER-D The importance of Medical records being maintained by HIM is that the patient records: a) Are evidence used in assessing the quality of care b) Are the primary source for clinical data required for reimbursement by health plans and liability payers C) Are the strongest evidence and defense in the event of a Medicare Audit d) Are the evidence cited in quality review - ANSWER-B Medicare patients are NOT required to produce a physician order to receive which of these services a) Diagnostic Mammography, flu vaccine, or B-12 shots b) Diagnostic Mammography, flu vaccine, or pneumonia vaccine c) Screening Mammography, flu vaccine or pneumonia vaccine d) Screening Mammography, flu vaccine or B-12 shots - ANSWER-C c) Fixed Contracting d) Contracted Rebating - ANSWER-D 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 - ANSWER-A 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 recovery" team d) Brought immediately to management's attention - ANSWER-A 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. - ANSWER-C 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 - ANSWER-A 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 a" or "part b" benefits d) Patients receive significant discounting on services contracted by the federal government - ANSWER-C Once the EMTALA requirements are satisfied a) Third-party payer info should be collected from the pt 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 pt then assumes full liability for services unless a third-party payer is notified or the pt applies for financial assistance within the first 48 hours d) The remaining registration processing is initiated either at the bedside or In a registration area - ANSWER-A The soft cost of a dissatisfied customer is a) The "cost" of staff providing extra attention in trying to perform service recovery b) The customer passing on info about their negative experience to potential pts or through social media channels c) Potentially negative treatment outcomes leading to expanding length-of-stay d) Lowered quality outcomes for the dissatisfied pt - ANSWER-B Concurrent review and discharge planning a) Occurs during service b) Is performed by the health plan during the time of service c) Is a significant part of quality and is performed by the clinical treatment team d) Is performed at discharge with the pt - ANSWER-A In a self-insured (or self-funded) plan, the costs of medical care are a) Borne by the employer on a pay-as-you-go basis b) Backed-up by stop-loss insurance against a catastrophic claim c) Mandated by the Affordable Care Act for small businesses unable to obtain commercial coverage d) Created by a combination of employer and employee contributions - ANSWER-A In choosing a setting for pt financial discussions, organizations should first and foremost a) Have processes in place to document the discussions b) Assess locations for convenience, professionalism, and comfort c) Respect the pts privacy d) Ensure all staff involved are properly trained and the pt financial education is included in all discussions - ANSWER-C All of the following are steps in safeguarding collections EXCEPT a) Placing collections in a lock-box for posting review the next business day b) Posting the payment to the pts account c) Completing balance activities d) Issuing receipts - ANSWER-D Which option is a government-sponsored health care program that is financed through b) Managing of expense budgets c) Effective HIM planning d) Generation of timely and accurate billing - ANSWER-A 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 - ANSWER-A Charges are the basis for a) Third party and regulatory review of resources used b) Evaluating quality c) Separation of fiscal responsibilities between the pt and the health plan d) Demonstrating medical necessity - ANSWER-C Chapter 13 Bankruptcy, debtor rehabilitation is a court proceeding a) That reorganizes a debtor's holdings and instructs creditors to look to the debtors' future earnings for payment b) That establishes a payment priority order to creditos' 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 - ANSWER-A Pt financial communications best practices produce communications that are a) Timely and remind pts of their financial responsibilities b) Consistent, clear and transparent c) Current and report the status of a pts claim d) Timely, comprehensive and specifying next steps - ANSWER-B 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 - ANSWER-B 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 - ANSWER-C A recurring/series registration is characterized by a) The creation of one registration record for multiple days of service b) The creation of multiple registrations for multiple services c) The creation of one registration record per diagnosis per visits d) The creation of multiple pt types for one date of service - ANSWER-A It is important to have high registration quality standards because a) Inaccurate or incomplete pt data will delay payment or cause denials b) Incomplete registrations will trigger exclusion from Medicare participation c) Inaccurate registration may cause discharge before full treatment is obtained d) Incomplete registrations will raise satisfaction scores for the hospital - ANSWER-A When recovery audit contractors (RAC) identify improper payments as over payments the claims processing contractor must a) Assume legal responsibility for repaying the overage amount b) Make recovery of the overpayment the top processing priority c) Send a demand letter to the provider to recover the over payment amount d) Conduct an audit of all the effected providers claims within the past 12 months - ANSWER-C Internal controls addressing coding and reimbursement changes are put I place to guard against a) Underpayments b) Denials c) Compliance fraud by upcoding d) Charge master error - ANSWER-C The pt discharge process begins when a) The physician writes the discharge orders b) Clinical services are completed and pt accounts have all the info necessary to bill c) The physician writes the discharge orders and the third-party payer sign-off on the necessity of the services provided d) Clinical services are completed, pt accounts can generated and accurate bill and there is agreement o the handling of pt financial responsibilities - ANSWER-A Most major health plans including medicare and Medicaid, offer a) Toll free verification hot lines, staffed around the clock b) Electronic and/or web portal verification c) Pt "verification of benefits" cards d) A grace period for obtaining verification within 72 hours of treatment - ANSWER-B