Revenue Cycle Management in Healthcare, Exams of Nursing

Download Revenue Cycle Management in Healthcare and more Exams Nursing in PDF only on Docsity! CMAA Module 6 Revenue Cycle - correct answer ✔✔A series of administrative functions that are required to capture and collect payment for services provided by a health care organization. Patient statements should be - correct answer ✔✔sent out on a regular basis, and outstanding balances need to be monitored. Any nonpayment from the patient requires collection activities. Revenue cycle begins - correct answer ✔✔Registering and scheduling Revenue Cycle ends - correct answer ✔✔they have received the final payment for services The patient experience can be affected throughout a patient's health care journey, including the revenue cycle. What are some of the actions that impact the patient experience related to billing? - correct answer ✔✔Collecting precise demographic information, accurate data-entry, verifying accurate coding, and timely billing all impact the patient experience. Complete and accurate claims promote a healthy revenue cycle and build patient trust and confidence in the organization. Today, most health care organizations use a - correct answer ✔✔practice management system (PMS) to perform revenue cycle tasks and streamline front office and back office workflows with automation The practice management system is an efficient way - correct answer ✔✔to boost productivity and can help with sustainability and stronger financial performance. Scheduling appointments, charge capture, coding, billing, generating financial/aging reports, generating patient statements, and managing the accounts receivable are all examples of how the PMS is efficiently used. Practice Management System PMS - correct answer ✔✔An efficient way to electronically manage administrative functions, such as scheduling appointments, integrating patient documentation from electronic health records, coding, billing, and revenue cycle tasks such as running aging reports and managing the accounts receivable. Phases of Revenue Cycle Registration and Scheduling - correct answer ✔✔This step occurs when the patient calls for an appointment. The CMAA will gather patient information such as demographic and insurance information, determine the type of appointment needed, and enter the appointment on the provider's schedule. During appointment scheduling, the patient may be asked to arrive 15 min early to complete new patient registration forms or update existing information. Phases of Revenue Cycle PT Check in - correct answer ✔✔The patient completes the registration (demographic and insurance), HIPAA, and other compliance and policy forms, along with medical history information. The CMAA will scan or copy the patient's insurance card and cross-check the information completed on the registration form to the data entered in the practice management system (PMS) during the registration and scheduling step, then changes the patient's status to checked in. Phases of Revenue Cycle Utilitzation Management Review - correct answer ✔✔Also known as utilization review (UR), this is the process of ensuring the patient has the appropriate referral, precertification, predetermination, or preauthorization as needed. This process supports the revenue cycle by ensuring the payer, provider, and patient have met any required conditions and understand how the service will be reimbursed and what the patient responsibility amount will be. Not all services or procedures will require a UR. The CMAA must be familiar with rules and guidelines for third-party payers, as they will vary. When in doubt, always verify by contacting the payer to determine if UR is necessary for the procedure or service. Documentation of UR is important for scheduling and claims purposes. For example, once a preauthorization is obtained, document the authorization number, expiration date, and any specified details in the patient's health record. Prior to the procedure or service being performed, verify that the authorization is still valid. It is possible for a procedure to be rescheduled due to various circumstances, and the authorization is no longer valid. In these cases, a request for an extension or new authorization must be obtained and documented in the PMS. A patient's eligibility must also be verified when scheduling. Using preauthorization as an example, the authorization provides approval for the procedure or service, yet reimbursement is still contingent on the eligibility of the patient at the time of service and is based on the claim details to support medical necessity. precertification - correct answer ✔✔Finding out if the service is covered by the patient's plan. predetermination - correct answer ✔✔Determining the payer's reimbursement amount for the service. preauthorization - correct answer ✔✔Finding out if the payer considers a service medically necessary based on the patient's specific condition. An insurance authorization is the process - correct answer ✔✔of obtaining approval from the patient's payer. Authorizations are obtained in advance of the test, imaging, medical equipment or device, procedure, or other service and are usually referred to as preauthorization. Describe when the revenue cycle starts and when it ends. - correct answer ✔✔The revenue cycle begins with patient registration and scheduling and ends when the claim is paid in full. The revenue cycle maintains the financial stability of the health care organization. Briefly describe how practice management systems impact the health care organization. - correct answer ✔✔Practice management systems are an efficient way to boost productivity and streamline with automation patient A/R controls, appointment scheduling, charge capture, generating financial reports and patient statements. They are efficient examples of how to utilize the PMS system to remain sustainable and improve patient outcomes. A patient is scheduled for an appointment tomorrow, and the CMAA notices the authorization number has expired and must be extended or a new authorization number obtained. Which of the following steps of the revenue cycle involves obtaining and verifying prior authorizations for certain procedures? A Patient check-in B Health care encounter and documentation C Utilization management review D Payer adjudication - correct answer ✔✔C Utilization management review Utilization review management is the process of verifying coverage and obtaining authorizations for certain services and procedures prior to performing the service for insurance reimbursement. Briefly describe charge capture and coding as it applies to the revenue cycle. - correct answer ✔✔Charge capture and coding is the process of entering the CPT, HCPCS, and ICD-10-CM codes associated with the patient encounter to prepare the claim for submission to the insurance payer. Reimbursement for services rendered are not paid unless charges are entered into the PMS, coded correctly, and submitted to the insurance payer. Why might a preauthorization be necessary prior to performing a procedure? - correct answer ✔✔Preauthorization may be necessary prior to a service because the insurance payer does not want to be responsible for reimbursement on services they consider not medically necessary. The CMAA will contact the payer and provide patient health history information to describe the medical necessity of the service. Describe when a referral would be needed for patient care. - correct answer ✔✔A referral may be needed for patient care when a patient is in need of more specialized care and treatment. For example, when a primary care provider refers a patient to the cardiologist for management of heart disease. Mistakes are bound to happen, and by grouping the day's work into _______ it is easier to find any posting errors and helps make locating the error less cumbersome. - correct answer ✔✔batches Batch - correct answer ✔✔a collection of all charges and payments entered for a particular date or time period. Each batch will have a unique identifier for reference in the future. This unique identifier will help identify an outstanding claim when referencing the aging reports. There may be multiple batches open by multiple operators at any given time. Charge entry can be accomplished by - correct answer ✔✔ntering codes directly into the patient encounter, using search fields or drop-down menus for the CPT, HCPCS, and ICD-10-CM codes associated with the encounter. The encounter form is used to - correct answer ✔✔communicate the services rendered to the patient and the corresponding codes for claims billing purposes. Based on the organization's EHR and PMS, the CMAA may be responsible for importing codes and related charges into the billing module. Regardless of how the charges are entered into the system, one task often associated with CMAAs is to reconcile the charges for the day. Once all the patient charges are entered, compare - correct answer ✔✔the daily total charge amount on the daily batch to the total charges on the encounter forms or entered into the PMS to make sure they match. If the charges match on the encounter forms or daily batch, everything is in balance. If they do not match, then it will be necessary to review each encounter form and compare it to the charges entered in the PMS to locate the charge entry error. Once the error is identified, make the correction, and check the totals again. Describe the components of a daily batch within the PMS. - correct answer ✔✔A daily batch is a collection of all transactions performed throughout the day. This includes posting charges for the encounter and payments from the patient and payer along with any adjustments made per the payer/provider contract. When posting the daily batch for the day's work, it is discovered that the payments entered in the PMS and the payments showing in the journal do not match. How can this issue be resolved prior to closing the daily batch? - correct answer ✔✔It will be necessary to review the payments posted in the PMS for each patient payment and the payments from the insurance payer and compare each payment to the daily ledger and the payer remittance advice. Government insurance plans are further classified as - correct answer ✔✔federal or state programs Medicare - correct answer ✔✔is a federal government program for individuals over a certain age (65), those with qualifying disabilities, or those who have end-stage renal disease. Medicaid - correct answer ✔✔s the term for state benefit programs that are available to qualifying individuals. Medicaid qualifications vary from state to state and can include income levels or medical needs as requirements. Tricare - correct answer ✔✔TRICARE is a federal payer for military members and eligible family members. auto insurance MedPay policy and workers' compensation. These plans would be used for - correct answer ✔✔specific conditions or injuries. The CMAA should contact the patient's auto insurance or workers' compensation carrier to confirm coverage prior to seeing the patient. When the wrong insurance is selected for a claim, it will be denied, causing a delay in reimbursement. Types of Payers Government State and federal programs examples - correct answer ✔✔Medicare, Medicaid, TRICARE Types of Payers Commercial - health insurance plans offered by commercial companies - correct answer ✔✔Examples: Aetna, United Healthcare, Cigna _____ is the largest insurance program in the United States and is administered by the Centers for Medicare and Medicaid Services (CMS). - correct answer ✔✔Medicare Medicare Part A: Covers, Requires Beneficiary Premium? - correct answer ✔✔Inpatient hospital charges No Medicare Part B Covers, Requires Beneficiary Premium? - correct answer ✔✔Ambulatory care Primary and secondary care Most outpatient services Yes Medicare Part C Covers. Requires Beneficiary Premium? - correct answer ✔✔Combines Part A and B coverage Vision Dental Yes Medicare Part D Covers. Requires Beneficiary Premium? - correct answer ✔✔Prescription medication Yes __________________- is funded both by the federal and state government and managed at the state level. - correct answer ✔✔Medicaid Health Risk Assessment - correct answer ✔✔A comprehensive patient questionnaire to assess overall well-being by measuring physical and mental health, including lifestyle factors, fall risk, and cognitive function. The outpatient/professional service claim formats are - correct answer ✔✔837P for electronic claims CMS-1500 for paper claims. Inpatient claim formats are - correct answer ✔✔837I for electronic claims and UB-04 (CMS-1540) for paper claims. The standard code sets used on claim forms are CPT, ICD-10-CM, ICD-10-PCS (for inpatient claims), and HCPCS codes used to describe the diagnoses, services, supplies, and procedures on the claim form.q - correct answer ✔✔ Timely Filling - correct answer ✔✔The length of time from the date of service in which a health care organization may submit a claim to the third-party payer. Timely filing varies by payer and may range from 90 days to one year from the date of service. Claims that exceed timely filing are not payable. A is an organization that accepts claims data from a health care organization, formats the claim, and submits it to the third-party payer. - correct answer ✔✔clearinghouse Typical reasons for claim rejections include: - correct answer ✔✔Incorrect, invalid, or nonspecific diagnosis codes Invalid or incorrect procedure codes Incorrect or missing modifiers Mismatched place of service to type of service Missing provider or organization NPI number Clearinghouse - correct answer ✔✔An organization that accepts the claims data from a health care provider, performs edits comparable to payer edits, and submits clean claims to the third-party payer. Which of the following would qualify a patient to be eligible for Medicare? A A 55-year-old patient B A 55-year-old patient who has end-stage renal disease C A healthy 5-year-old patient D A 5-year-old patient with acute tonsilitis - correct answer ✔✔B A 55-year-old patient who has end-stage renal disease A patient will qualify for Medicare if they have end-stage renal disease. Which of the following insurance programs include income levels? A Medicare B BlueCross Blue Shield C Medicaid D TRICARE - correct answer ✔✔C Medicaid Medicaid is a state-run program that can assist with medical needs for qualifying patients. Low income is considered one of the qualifying circumstances. Match the payment model definition with the correct payment model type. - correct answer ✔✔Pay-for- performance changes the focus to value-based care, rather than volume-based care. Fee-for-service reimburses based on the service or procedure performed. Value-based payment models reward the provider with incentive payments for meeting defined program performance standards. Capitation is a set amount paid per month per patient. Briefly describe how a capitation payment plan reimburses the provider. - correct answer ✔✔Capitation is a payment model where the health care organization agrees to a set reimbursement amount per patient per month. When a patient is seen, charges for the encounter are encompassed into the monthly payment. Whether the patient is seen three times in a month or seven times in a month, the monthly reimbursement rate is the same. There are many health care payment models. When the provider receives an incentive for providing an annual wellness visit, which of the following payment models is the provider participating in? An aging report can be generated to determine balances owed by the patient. This report identifies outstanding patient balances that are considered overdue. Collecting patient balances is an important part of the revenue cycle and should be monitored and managed regularly. - correct answer ✔✔ A patient presents to the office and pays the set amount for the office visit of $25. Which of the following types of payment was received from the patient? A Coinsurance B Deductible C Premium D Copay - correct answer ✔✔D Copay The set amount determined by the insurance payer for office visits, specialists, and even ER visits is known as the copay. Describe when the patient's coinsurance will go into effect. - correct answer ✔✔Once the patient has met the annual deductible, the coinsurance will go into effect. Then the insurance and patient will pay a percentage of the billed services. Briefly describe the importance of balancing daily transactions. - correct answer ✔✔It is necessary to balance the daily transactions because entry errors are easier to find and correct. All transactions should balance before posting. If transactions are not reconciled daily, it will be more difficult to locate any entry errors. Briefly describe a contractual adjustment. - correct answer ✔✔An adjustment is the difference between the billed amount and the allowed amount. This difference must be adjusted from the patient account. Briefly describe timely filing. - correct answer ✔✔Timely filing is the length of time in which a health care organization may submit a claim to the third-party payer from the date of service. non-participating (non-PAR) provider - correct answer ✔✔Does not agree to a payer's allowed amount and is not required by contract to do so. This may be referred to as out-of-network for managed care payers. participating (PAR) provider - correct answer ✔✔Agrees to accept the payer's allowed amount (regardless of the billed amount). This may be referred to as in-network for managed care payers. A sliding scale repayment plan allows - correct answer ✔✔the patient to pay a lower monthly rate depending on the debt-to-income ratio. The plan may also take into consideration regular monthly bills and outstanding medical bills. If the patient meets the sliding scale requirements, a monthly payment amount is agreed upon for a given period of time, typically one year, and the patient will need to reapply each year. Briefly describe the difference between an in-network provider and an out-of-network provider. - correct answer ✔✔An in-network provider is contracted, so they accept the payers fee schedule rate, even when it is less than the amount billed. Out-of-network providers are not contractually obligated to accept the in-network fee schedule rate. Briefly describe why the health care organization would file an appeal. - correct answer ✔✔When a claim or itemized service from a claim is denied or not paid as expected. Briefly describe the Special Needs Plan (SNP) program offered by Medicare Advantage Plans. - correct answer ✔✔The Special Needs Plan is for Medicare Advantage qualifying beneficiaries who face challenges such as needing assistance with activities of daily living or have cognitive impairment. Based on the case study, the CMAA identified potential issues with a provider's schedule. Which of the following phases of the revenue cycle initially brought this issue to the forefront? A Patient check-in B Health care encounter and documentation C Utilization review management D Registration and scheduling - correct answer ✔✔D Registration and scheduling Patient registration and scheduling is the step in which the provider schedules can be seen. It was noticed that the provider is seeing many more patients than other providers, causing concern. Based on the case study, the CMAA reviewed the documentation for appropriate code reporting. Which of the following phases of the revenue cycle refers to the documentation process? A Patient check-in B Health care encounter and documentation C Utilization review management D Registration and scheduling - correct answer ✔✔B Health care encounter and documentation The health care encounter and documentation phase of the revenue cycle where the provider will record the elements of the encounter and the CMAA or billing staff can review the notes for proper code selection. Briefly describe the purpose of the utilization review management phase of the revenue cycle. - correct answer ✔✔The purpose of utilization review management is to align the patient services with payer requirements. This is done not only to provide the appropriate care but also to ensure that services will be reimbursed. Briefly describe the type of situation that would require privacy, empathy, and professionalism in a special circumstance. - correct answer ✔✔A patient expressing concern about not being able to provide payment at the time of service is a special circumstance that requires management approval. There will also be times a patient is emotional, such as the loss of a spouse, and may require a private location to openly discuss their situation.