Revenue Cycle Management in Healthcare, Exams of Nursing

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HFMA CRCR Exam Questions with 100% Correct Answers 2024 Through what document does a hospital establish compliance standards? - Correct answer-code of conduct What is the purpose OIG work plant? - Correct answer-Identify Acceptable compliance programs in various provider setting If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - Correct answer-Non-diagnostic service provided on Tuesday through Friday What does a modifier allow a provider to do? - Correct answer-Report a specific circumstance that affected a procedure or service without changing the code or its definition IF outpatient diagnostic services are provided within three days of the admission of a Medicare beneficiary to an IPPS (Inpatient Prospective Payment System) hospital, what must happen to these charges - Correct answer-They must be billed separately to the part B Carrier what is a recurring or series registration? - Correct answer-One registration record is created for multiple days of service What are nonemergency patients who come for service without prior notification to the provider called? - Correct answer-Unscheduled patients Which of the following statement apply to the observation patient type? - Correct answer-It is used to evaluate the need for an inpatient admission which services are hospice programs required to provide around the clock patient - Correct answer-Physician, Nursing, Pharmacy Scheduler instructions are used to prompt the scheduler to do what? - Correct answer- 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? - Correct answer-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: - Correct answer-Documentation of the medical necessity for the test What core financial activities are resolved within patient access? - Correct answer- scheduling , pre-registration, insurance verification and managed care processing What is an unscheduled direct admission? - Correct answer-A patient who arrives at the hospital via ambulance for treatment in the emergency department When is it not appropriate to use observation status? - Correct answer-As a substitute for an inpatient admission Patients who require periodic skilled nursing or therapeutic care receive services from what type of program? - Correct answer-Home health agency Every patient who is new to the healthcare provider must be offered what? - Correct answer-A printed copy of the provider privacy notice Which of the following statements apples to self insured insurance plans? - Correct answer-The employer provides a traditional HMO health plan In addition to the member's identification number, what information is recorded in a 270 transaction - Correct answer-Name What process does a patient's health plan use to retroactively collect payments from liability automobile or worker's compensation plan? - Correct answer-Subrogation In what type of payment methodology is a lump sum of bundled payment negotiated between the payer and some or all providers? - Correct answer- 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? - Correct answer-Site of service limitation Which of the following statements applies to private rooms? - Correct answer-If the medical necessity for a private room is documented in the chart. The 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? - Correct answer-It is necessary to ask the patient each of the MSP questions Which of the following is not true of Medicare Advantage Plans? - Correct answer-A patient must have both Medicare Part A and B benefits to be eligible for a Medicare Advantage plan Which of the following is a valid reason for a payer to deny a claim? - Correct answer- Failure to complete authorization Which of the following statements is NOT a possible consequence of selecting the wrong patient in the MPI(master patient index) - Correct answer-Claim is paid in full Which of the following statements is true of a Medicare Advantage Plan? - Correct answer-This plan supplements Part A and Part B benefits Which is the following is not a characteristic of Medicaid HMO plan? - Correct answer- Medicaid-eligible patients are never required to join a Medicaid HMO plan Which of the following is violation of the EMTALA ? - Correct answer- Registration staff members routinely contact managed care plans for prior authorizations before the patients is seen by the on duty physician Which of the following statements is true of the important message from Medicare notification requirements? - Correct answer-Notification can be issued no earlier than 7 days before admission and no more than 2 days before discharge. What is the self pay balance after insurance - Correct answer-The portion of the adjudicated claim that is due from the patient Which of the following options is an alternative to valid long term payment plans - Correct answer-Bank loans The patient has the following benefit plan $400 per family member deductible, to a maximum of $1200 per year and $2000 per family member co insurance, to a family maximum of $6000 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? - Correct answer-$6000 What type of plan restricts benefits for non-emergency care to approve providers only? - Correct answer-A POS (point of service )plan What does scheduling allow provider staff to do? - Correct answer- Review the appropriateness of the service requested When an adult patient is covered by both his own and his spouse health insurance plan, which of the statements is true? - Correct answer-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 financial status? - Correct answer-Demographic, Income, Assets and Expenses. HIPAA privacy rules require covered entities to take all, of the following actions EXCEPT: - Correct answer-Use only designated software platforms to secure patient date. When Recovery Audit Contractors (RAC) identify improper payments as overpayment. the claims processing contractor must: - Correct answer- Send a demand letter to the provider to recover the over payment amount. Which HIPPA transaction set provides electronic processing of 8insurance verification requests and responses? - Correct answer-The 270-271 set Across all care settings, if a patient consents to a financial discussion during a medical encounter to expedite discharge, the HFMA best practice is to: - Correct answer- Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow. A scheduled inpatient represents an opportunity for the provider to do which of the following? - Correct answer-Complete registration and insurance approval before service The Medicare Bundled Payments for Care Initiative (BCP) is designed to: - Correct answer-Align incentives between hospitals, physicians, and non- physician providers in- order to better coordinate patient care. To maximize the value derived from customer complaints, all consumer complaints should be: - Correct answer-Tracked and shared to improve customer experience The soft cost of a dissatisfied customer is: - Correct answer-The customer passing on information about their negative experience to potential patients or through social media channels. Applying the contracted payment methodology to the total charges yields: - Correct answer-An estimate price The importance of medical records maintained by HIM is that the patient records: - Correct answer-Are the primary source for clinical data required for reimbursement by health plans and liability payers Important Revenue Cycle Activities in the pre-service stage include: - Correct answer- Obtaining or updating patient and guarantor information In the pre-service stage, the cost of the schedule services is identified and the patient's health plan and benefits are used to calculate: - Correct answer-The amount the patient may be expected to pay after insurance. The disadvantage of outsourcing includes all, of the following Except - Correct answer- Reduces internal staffing costs and a reliance on outsourced staff. Marinating routine contact with health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of who: - Correct answer-Case Management A claim is denied for the following reasons EXCEPT: - Correct answer-The submitted claim does not have the physician signature All Hospitals are required to establish a written financial assistance policy that applies to: - Correct answer-All emergency and medically necessary care Examples of ethics violation that impact the revenue cycle include all of the following EXCEPT: - Correct answer-Seeking payment options for self-pay Verbal orders from a physician for a service(s) are: - Correct answer- Acceptable if given to "qualified" staff as defined in a hospitals policies and procedures Medicare has established guidelines called Local Coverage Determination (LCD) and National Coverage Determination (NCD) that establish: - Correct answer-What serviced or healthcare items are covered under Medicare? A decision on whether a patient should be admitted as an inpatient or become an outpatient observation patient requires medical judgement based on all of the following EXCEPT: - Correct answer-The patient's home care coverage What is the first step of the daily cash reconciliation process? - Correct answer- Obtaining cash, check, credit card and debit card payment from that day The healthcare industry is vulnerable to compliance issues, in large part due to the complexity of the statutes and regulations pertaining to: - Correct answer-Medicare and Medicaid payments The correct coding initiative program consist of: - Correct answer- Edits that are implemented within provider's claim processing system The Affordable Health Care Act legislated the development of Health Insurance Exchange, where individuals and small businesses can: - Correct answer-Purchase health benefits plans regardless of insured's health status Before classifying and subsequently writing off an account to financial assistance or bad debit, the hospital must establish policy define appropriate answer-Pre-authorization are obtained For scheduled patients, important revenue cycle activities in the time-of - service stage DO NOT include: - Correct answer-Final bill is presented for payment If a medical service authorization, who is typically responsible for obtaining the authorization: - Correct answer-The provider scheduling Concurrent review and discharge planning - Correct answer-Occurs during service The fundamental approach in managing denials is: - Correct answer-To analyze the type and sources of denials and consider process changes to eliminate further denials The first thing a health plan does when processing a claim is: - Correct answer-Check if the patient is a health plan beneficiary and what is the coverage Outsourcing options should be evaluated as - Correct answer-Any other business service purchase Insurance verification results in which of the following: - Correct answer- The accurate identification of the patient's eligibility and benefits EMTLA and HFMA best practices specify that in an Emergency Department setting: - Correct answer-No patient financial discussions should occur before a patient is screened and stabilized he HCCAHPS (Hospital Consumer Assessment of Healthcare Provider's and Systems) initiative was launched to: - Correct answer-Provide a standardized method for evaluation patients' perspective on hospital care All of the following are potential causes of credit balances EXCEPT: - Correct answer-A patient's choice to build up a credit against future medical bills Medicare will only pay for tests and services that: - Correct answer-Can be demonstrated as necessary This was developed to promote and ensure healthcare quality and value and also to protect consumers and workers in the healthcare system. This directive is called: - Correct answer-Joint Commission for Acceleration of Healthcare Organizations (JCAHO) safety standards It is important to calculate reserves to ensure: - Correct answer-A stable financial operations and accurate financial reporting An advantage of a pre-registration program in - Correct answer-The opportunity to reduce processing times at the time of service The code indication of the disposition of the patient at the conclusion of service is called the: - Correct answer-Patient discharge status code HIPPA has adopted Employer Identification Numbers (EINs) to be used in standard transactions to identify the employer of an individual described in a transaction. EINs are created and assigned by: - Correct answer-The Internal Revenue Service The purpose of the ACA mandated Community Health Needs Assessment is: - Correct answer-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: - Correct answer-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 - Correct answer-Identify past due accounts likely to become bad debit Applying the contracted payment amount to the amount of total charges yields: - Correct answer-An estimated price for the patient's responsibility Most major health plans including Medicare and Medicaid offer: - Correct answer- Electronic and/or web portal verification What are some elements of a board-approved financial assistance policy: - Correct answer-Eligibility application process and nonpayment collection activities Which of the following is usually covered on a Conditions of Admissions form: - Correct answer-Patient's bill of rights. Net Accounts Receivable is - Correct answer-The amount an entity is reasonably confident of collection form overall accounts A common billing issue with hospital-based physician's is - Correct answer- They are not contracted with the patient's health plan to provide services What are collection agency fees based on ? - Correct answer-A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - Correct answer-Birthday What customer service improvements might improve the patient accounts department? - Correct answer-Holding Staff accountable for customer service during performance reviews What is an ABN(Advance Beneficiary Notice of Non-coverage) required to do? - Correct answer-Inform Medicare beneficiary that Medicare may not pay for the order or service What is the initial hospice benefit? - Correct answer-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? - Correct answer-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 - Correct answer-They are not being processed in a timely manner What are the two statutory exclusions from hospice coverage? - Correct answer- Medically Unnecessary services and custodial care What statement applies to the scheduled outpatient? - Correct answer-The services do not include an overnight stay How is a mis-posted contractual allowance resolved? - Correct answer- 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? - Correct answer-Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - Correct answer-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 - Correct answer-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? - Correct answer- Neither enrolled not entitled to benefits Regulation Z of the consumer Credit Protection Act, also known as the Truth in lending Act establishes what? - Correct answer-Disclosure rules for consumer credit sales and consumer loans What is a principle diagnosis? - Correct answer-Primary reason for the patients admission