Revenue Cycle Management in Healthcare, Exams of Nursing

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CRCR Certification Exam Questions and Answers

2024/25 Latest Exam Guide.

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 - ☑️☑️ 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) - ☑️☑️ b) Judicial

review by a federal district court 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 - ☑️☑️ a) The principles and standards by

which organizations operate 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 - ☑️☑️ a) Charitable pledges

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 - ☑️☑️ c)

Which diagnoses, signs, or symptoms are reimbursable 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 - ☑️☑️ c) The time it takes to collect anticipated

revenue 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 - ☑️☑️ b) The fact that

charge master lists the total charge, not net charges that reflect charges after a payer's contractual adjustment 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 b) Have a patient responsibilities kit ready for the patient, containing all of the required registration forms and instructions 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 - ☑️☑️ c) Support that choice, providing that the discussion does not

interfere with patient care or disrupt patient flow 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 -

☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ a) The court liquidates the debtor's nonexempt property, pays

creditors, and discharges the debtor from the debt

14. 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 d) Scheduling, pre-registration, registration, medical necessity screening and

patient refunds - ☑️☑️ a) Scheduling, pre-registration, insurance verification and

managed care processing

15. 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 - ☑️☑️ d) A mutual hold-harmless clause

16. 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 - ☑️☑️ d) Case Management

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 - ☑️☑️ a) Revenue codes

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 - ☑️☑️ a)

Monitor compliance 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 - ☑️☑️ b)

Should take place between the patient or guarantor and properly trained provider representatives The purpose of a financial report is to: a) Provide a public record, if requested b) Present financial information to decision makers c) Prepare tax documents

d) Monitor expenses - ☑️☑️ b) Present financial information to decision makers

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 -

☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 -

☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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

d) An electronic transfer of funds from payer to payee - ☑️☑️ d) An electronic

transfer of funds from payer to payee Revenue cycle activities occurring at the point-of-service include all 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 - ☑️☑️ c) Providing charges to the third-party payer

as they are incurred 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 - ☑️☑️ b) Until the beneficiary is "hospitalization and/or skilled

nursing facility-free" for 60 consecutive days 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 - ☑️☑️ b) Provide a method

of measuring the collection and control of A/R 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 - ☑️☑️ b) Patients should be given the opportunity to request a

patient advocate, family member, or other designee to help them in these discussions 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

• ☑️☑️ d) Ensure that she/he accesses the correct information in the historical database 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 - ☑️☑️ a) Explain to

the patient their financial responsibility and to determine the plan for payment 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 - ☑️☑️ 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 -

☑️☑️ 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 -

☑️☑️ 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 -

☑️☑️ d) Inaccurate or incomplete patient data will delay payment or cause

denials 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" - ☑️☑️ d) Medicare

determines are "reasonable and necessary" 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 - ☑️☑️ d) From the midnight census

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 - ☑️☑️ c) Accurate billing

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 record is completed so that the proper coding can be

initiated - ☑️☑️ c) The remaining registration processing is initiated at the

bedside or in a registration area 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 - ☑️☑️ d) Patient bill of rights

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. -

☑️☑️ c) Complete registration and insurance approval before service

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 - ☑️☑️ c) Verifying the patient's

identification 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