Revenue Cycle Management in Healthcare, Exams of Nursing

Download Revenue Cycle Management in Healthcare and more Exams Nursing in PDF only on Docsity! 2023-2024 HFMA CRCR EXAM QUESTIONS AND ANSWERS (100% ACCURATE) 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 requested 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 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 $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? $6000 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 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 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