Revenue Cycle Management in Healthcare, Exams of Advanced Education

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HFMA CRCR 2023 - 2024 LATEST EXAM UPDATE

Through what document does a hospital establish compliance standards? - code of conduct What is the purpose OIG work plant? - 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? - Non-diagnostic service provided on Tuesday through Friday What does a modifier allow a provider to do? - Report a specific circumstance that affected a procedure or service without changing the code or its definition IF outpatient diagnostic services are provided within three days of the admission of a Medicare beneficiary to an IPPS (Inpatient Prospective Payment System) hospital, what must happen to these charges - They must be billed separately to the part B Carrier what is a recurring or series registration? - 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? - Unscheduled patients Which of the following statement apply to the observation patient type? - It is used to evaluate the need for an inpatient admission which services are hospice programs required to provide around the clock patient - Physician, Nursing, Pharmacy Scheduler instructions are used to prompt the scheduler to do what? - Complete the scheduling process correctly based on service requeste The Time needed to prepare the patient before service is the difference between the patients arrival time and which of the following? - Procedure time Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: - Documentation of the medical necessity for the test What is the advantage of a pre-registration program - It reduces processing times at the time of service

What date are required to establish a new MPI(Master patient Index) entry - The responsible party's full legal name, date of birth, and social security number Which of the following statements is true about third-party payments? - The payments are received by the provider from the payer responsible for reimbursing the provider for the patient's covered services. Which provision protects the patient from medical expenses that exceed the pre-set level - stop loss what documentation must a primary care physician send to HMO patient to authorize a visit to a specialist for additional testing or care? - Referral Under EMTALA (Emergency Medical Treatment and Labor Act) regulations, the provider may not ask about a patient's insurance information if it would delay what? - Medical screening and stabilizing treatment Which of the following is a step in the discharge process? - Have a case management service complete the discharge plan The hospital has a APC based contract for the payment of outpatient services. Total anticipated charges for the visit are $2,380. The approved APC payment rate is $780. Where will the patients benefit package be applied? - To the approved APC payment rate A patient has met the $200 individual deductible and $900 of the $1000 co-insurance responsibility. The co-insurance rate is 20%. The estimated insurance plan responsibility is $1975.00. What amount of coinsurance is due from the patient? - $100. When is a patient considered to be medically indigent? - The patient's outstanding medical bills exceed a defined dollar amount or percentage of assets. What patient assets are considered in the financial assistance application? - Sources of readily available funds , vehicles, campers, boats and saving accounts If the patient cannot agree to payment arrangements, What is the next option? - Warn the patient that unpaid accounts are placed with collection agencies for further processing What core financial activities are resolved within patient access? - scheduling , pre-registration, insurance verification and managed care processing What is an unscheduled direct admission? - A patient who arrives at the hospital via ambulance for treatment in the emergency department

When is it not appropriate to use observation status? - As a substitute for an inpatient admission Patients who require periodic skilled nursing or therapeutic care receive services from what type of program? - Home health agency Every patient who is new to the healthcare provider must be offered what? - A printed copy of the provider privacy notice Which of the following statements apples to self insured insurance plans? - The employer provides a traditional HMO health plan In addition to the member's identification number, what information is recorded in a 270 transaction - Name What process does a patient's health plan use to retroactively collect payments from liability automobile or worker's compensation plan? - Subrogation In what type of payment methodology is a lump sum of bundled payment negotiated between the payer and some or all providers? - DRG/Case rate What Restriction does a managed care plan place on locations that must be used if the plan is to pay for the service provided? - Site of service limitation Which of the following statements applies to private rooms? - If the medical necessity for a private room is documented in the chart. The patients insurance will be billed for the differential Which of the following is true about screening a beneficiary of possible MSP(Medicare secondary payer) situations? - It is necessary to ask the patient each of the MSP questions Which of the following is not true of Medicare Advantage Plans? - 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? - 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) - Claim is paid in full Which of the following statements is true of a Medicare Advantage Plan? - This plan supplements Part A and Part B benefits

Which is the following is not a characteristic of Medicaid HMO plan? - Medicaid-eligible patients are never required to join a Medicaid HMO plan Which of the following is violation of the EMTALA? - 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? - 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 - 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 - Bank loans The patient has the following benefit plan $400 per family member deductible, to a maximum of $1200 per year and $2000 per family member co insurance, to a family maximum of $ per year excluding the deductible. Five family members are enrolled in this benefit plan. What is the maximum out of pocket expense that that family could incur during the calendar year? - $ What type of plan restricts benefits for non-emergency care to approve providers only? - A POS (point of service )plan What does scheduling allow provider staff to do? - Review the appropriateness of the service requested When an adult patient is covered by both his own and his spouse health insurance plan, which of the statements is true? - The patients insurance plan is primary Mrs. Jones , a Medicare beneficiary was admitted to the hospital on June 20,2010. As of the admission date, she had only used 8 inpatient days in the current benefit period. If she is not discharge on what date will Mr jones exhaust her full coverage days. - August 9, 2010 In order to meet eligibility guidelines for healthcare benefits, Medicaid beneficiaries must fall into a specified need category and meet what other types of requirements - Income and assets Fee for service plans pay claims based on a percentage of charges. How are patients out of pocket cost calculated? - They are calculated quarterly Indemnity plans usually reimburse what? - A certain percentage of charges after patient meets policy's annual deductible.

Departments that need to be included in Charge master maintenance include all EXCEPT - Quality Assurance Using HIPPA standardized transaction sets allow providers to: - Submit a standardized transaction to any of the health plans with which it conducts business. Which of the following is NOT included in the standardized quality measures? - Cost of services The ACO investment model will test the use of pre-paid shared savings to: - Encourage new ACOs to form in rural and underserved areas. Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons on a monthly fee is known as: - HMO Ambulance services are billed directly to the health plan for: - Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility. Any provider that has filed a timely cost report may appeal in an adverse final decision received from the Medicare Administrative Contractor (MAC), the appeal may be filed with: - The Provider Reimbursement Review Board. For scheduled payments, important revenue cycle activities in the time-of-service stage DO Not include: - Obtaining or updating patient and guarantor information Hospital can only convert an inpatient case to observation if: - The hospital utilization review committee determines before the patient is discharged and prior to billing that an observation setting would be more appropriate. Hospital need which of the following information sets to assess a patient's financial status? - Demographic, Income, Assets and Expenses. HIPAA privacy rules require covered entities to take all, of the following actions EXCEPT: - Use only designated software platforms to secure patient date. When Recovery Audit Contractors (RAC) identify improper payments as overpayment. the claims processing contractor must: - 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? - 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: - 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?

• Complete registration and insurance approval before service The Medicare Bundled Payments for Care Initiative (BCP) is designed to: - 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: - Tracked and shared to improve customer experience The soft cost of a dissatisfied customer is: - 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: - An estimate price The importance of medical records maintained by HIM is that the patient records: - 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: - 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: - The amount the patient may be expected to pay after insurance. The disadvantage of outsourcing includes all, of the following Except - 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: - Case Management A claim is denied for the following reasons EXCEPT: - The submitted claim does not have the physician signature All Hospitals are required to establish a written financial assistance policy that applies to: - All emergency and medically necessary care Examples of ethics violation that impact the revenue cycle include all of the following EXCEPT: - Seeking payment options for self-pay

Verbal orders from a physician for a service(s) are: - 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: - 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: - The patient's home care coverage What is the first step of the daily cash reconciliation process? - 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: - Medicare and Medicaid payments The correct coding initiative program consist of: - 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: - 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: - Monitor compliance The Electronic Remittance Advice (ERA) data sets are: - A standardized for that provides 3rd party payment details to providers The first and most critical step in registering a patient, whether scheduled or unscheduled is: - Verifying the patient's identification The standard claim form used for the billing by hospitals, nursing facilities, and other inpatient services is called the: - UB- 04 A four-digit number code established by the National Uniform Billing Committee (NUBC) that categorizes/classifies a line in the charge master is known as: - Revenue codes Internal controls addressing coding and reimbursement charges are put in place to guard against: - Compliance fraud by "upcoding"

The 501(R) regulations require non-for-profit providers (501) ©(3) organizations to do which of the following activities: - Complete a community needs assessment and develop a discount program for patient's balances after insurance payment During pre-registration, a search for the patient's MRI number is initiated using which of the following data sets: - Patient's full legal name and date of birth or the patient's Social Security number To maximize the value derived from customer complaints, all consumer complaints should be: - Tracked and shared to improve the customer experience The Business ethics, or organizational ethics represent: - The principles and standards by which organizations operate Providers are advised that it is best to establish patient financial responsibility and assistance policies and make sure they are followed internally and by: - Third-party payers The advantage to using a third-part, collection agency includes all of the following EXCEPT: - Providers pay pennies on each dollar collected. Local Coverage Determination (LCD) and National Coverage Determinations (NCD) are Medicare established guidelines used to determine: - Which diagnosis, signs, or symptoms are reimbursable Claims with the dates of service received later than one calendar year beyond the date of service will be: - Denied by Medicare in the pre-service stage, the requested service is screened for medical necessity, health plan coverage and benefits are verified and: - Pre-authorization are obtained For scheduled patients, important revenue cycle activities in the time-of - service stage DO NOT include: - Final bill is presented for payment If a medical service authorization, who is typically responsible for obtaining the authorization: - The provider scheduling Concurrent review and discharge planning - Occurs during service The fundamental approach in managing denials is: - 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: - Check if the patient is a health plan beneficiary and what is the coverage

Outsourcing options should be evaluated as - Any other business service purchase Insurance verification results in which of the following: - The accurate identification of the patient's eligibility and benefits EMTLA and HFMA best practices specify that in an Emergency Department setting: - No patient financial discussions should occur before a patient is screened and stabilized he HCCAHPS (Hospital Consumer Assessment of Healthcare Provider's and Systems) initiative was launched to: - Provide a standardized method for evaluation patients' perspective on hospital care All of the following are potential causes of credit balances EXCEPT: - A patient's choice to build up a credit against future medical bills Medicare will only pay for tests and services that: - 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: - Joint Commission for Acceleration of Healthcare Organizations (JCAHO) safety standards It is important to calculate reserves to ensure: - A stable financial operations and accurate financial reporting An advantage of a pre-registration program in - The opportunity to reduce processing times at the time of service To be eligible for Medicaid, an individual must: - Meet income and asset requirements The patient discharge process begins when: - The physician writes the order Appropriate training for patient financial counseling staff must cover all of the following EXCEPT: - Documenting the conversation in the medical records Patients should be informed that costs presented in a price estimation may: - 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 - HMO Chapter 11 Bankruptcy permits a debtor to: - Work out a court-supervised plan with creditors A portion of the accounts receivable inventory which has NOT qualified for billing includes: - Accounts created during pre-registration but not activated

Overall aggregate payments made to a hospice are subject to a computed "cap amount" calculated by: - 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: - The specificity and coding accuracy needed to support reimbursement claims Charges, as the most appropriate measurement of utilization, enables: - Generation of timely and accurate billing Days in A/R calculated based on the value of: - The total account receivable on a specific date Medicare benefits provide coverage for: - Inpatient hospital services, skilled nursing care. And home health care HFMA best practices call for patient financial discussions to be reinforced: - By issuing a new invoice to the patient All of following are steps in safeguarding collections EXCEPT: - 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: - 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: - The Internal Revenue Service The purpose of the ACA mandated Community Health Needs Assessment is: - To provide community benefit outreach to those without insurance and who have not had a physical within the past 2 years What is Continuum of Care: - The coordination and linkage of resource needed to avoid the duplication of services and the facilitation of seamless movement among care settings. Account Receivable (A/R) aging reports - Identify past due accounts likely to become bad debit Applying the contracted payment amount to the amount of total charges yields: - An estimated price for the patient's responsibility Most major health plans including Medicare and Medicaid offer: - Electronic and/or web portal verification

What are some elements of a board-approved financial assistance policy: - Eligibility application process and nonpayment collection activities Which of the following is usually covered on a Conditions of Admissions form: - Patient's bill of rights. Net Accounts Receivable is - The amount an entity is reasonably confident of collection form overall accounts A common billing issue with hospital-based physician's is - They are not contracted with the patient's health plan to provide services What are collection agency fees based on? - A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - Birthday What customer service improvements might improve the patient accounts department? - Holding Staff accountable for customer service during performance reviews What is an ABN(Advance Beneficiary Notice of Non-coverage) required to do? - Inform Medicare beneficiary that Medicare may not pay for the order or service What is the initial hospice benefit? - Two 90-day periods and an unlimited number of subsequent periods How should a provider resolve a late-charge credit posted after an account is billed? - Post a late-charge adjustment to the account an increase in the dollars aged greater than 90 days from date of service indicate what about accounts - They are not being processed in a timely manner What are the two statutory exclusions from hospice coverage? - Medically Unnecessary services and custodial care What statement applies to the scheduled outpatient? - The services do not include an overnight stay How is a mis-posted contractual allowance resolved? - Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount What type of patient status is used to evaluate the patients need for inpatient care? - Observation

Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - Medically necessary inpatient hospital services for at least 3 consecutive days before the skilled nursing care admission. When is the word "SAME" entered on the CMS 1500 billing form in feild 0 - When the patient is insured If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - Neither enrolled not entitled to benefits Regulation Z of the consumer Credit Protection Act, also known as the Truth in lending Act establishes what? - Disclosure rules for consumer credit sales and consumer loans What is a principle diagnosis? - Primary reason for the patients admission Collecting patient liability dollars after service leads to what? - Lower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - 50% of the current deductible amount What service provided to a Medicare beneficiary in a rural health clinic(RHC) is not billable as an RHC service? - Inpatient care What code indicates the disposition of the patient at the conclusion of service? - Patient discharge status code What are hospitals required to do for Medicare credit balance accounts? - They result in lost reimbursement and additional cost to collect. When an undue delay of payment results from a dispute between the patient and the third party payer, who is responsible for payment? - Patient With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what? - Access their information and perform functions on-line What date is required on all CMS 1500 claim forms? - onset date of current illness What code is used to report the provider's most common semiprivate room rate? - Condition code Regulations and requirements for coding accountable care organizations which allows providers to begin creating these organizations were finalized in - 2012

What is a primary responsibility of the recover audit contractor? - To correctly identify proper payments for Medicare part A and B claims How must providers handle credit balances? - Comply with state statutes concerning reporting credit balance What activities are completed when a scheduled pre-registered patient arrives for service? - Registering the patient and directing the patient to the service area In addition to being supported by information found in the patients chart, a CMS 1500 claim must be coded using what? - HCPCS What results from a denied claim? - The provider incurs rework and appeal costs