Medicare Regulations and Healthcare Insurance: Key Concepts and Processes, Exams of Nursing

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QUESTIONS AND ANSWERS EXAM 2024 COMPREHENSIVE MEDICAL CODING EXAMS TEST BANK: OVER 700 EXPERT- VERIFIED QUESTION WITH A+ ANSWER TESTED AND CONFIRMED A+ ANSWERS When does a hospital add ambulance charges to the Medicare inpatient claim? - ANSWER- If the patient requires ambulance transportation to a skilled nursing facility How should a provider resolve a late-charge credit posted after an account is billed? - 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 - ANSWER- They are not being processed in a timely manner What is an advantage of a preregistration program? - ANSWER- It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - ANSWER- Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - ANSWER- Scheduling, insurance verification, discharge processing, and payment of point-of- service receipts What statement applies to the scheduled outpatient? - ANSWER- The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - 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 patient's need for inpatient care? - ANSWER- Observation In addition to being supported by information found in the patient's chart, a CMS 1500 claim must be coded using what? - ANSWER- HCPCS (Healthcare Common Procedure Coding system) What results from a denied claim? - ANSWER- The provider incurs rework and appeal costs Why does the financial counselor need pricing for services? - ANSWER- To calculate the patient's financial responsibility What type of provider bills third-party payers using CMS 1500 form - ANSWER- Hospital-based mammography centers How are disputes with nongovernmental payers resolved? - ANSWER- Appeal conditions specified in the individual payer's contract The important message from Medicare provides beneficiaries with information concerning what? - ANSWER- Right to appeal a discharge decision if the patient disagrees with the services Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - ANSWER- To improve access to quality healthcare If a patient remains an inpatient of an SNF (skilled nursing facility for more than 30 days, what is the SNF permitted to do? - ANSWER- Submit interim bills to the Medicare program. 90. MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - ANSWER- 120 days passes, but the claim then be withdrawn from the liability carrier What data are required to establish a new MPI entry? - ANSWER- The patient's full legal name, date of birth, and sex What should the provider do if both of the patient's insurance plans pay as primary? - ANSWER- Determine the correct payer and notify the incorrect payer of the processing error What do EMTALA regulations require on-call physicians to do? - ANSWER- Personally appear in the emergency department and attend to the patient within a reasonable time At the end of each shift, what must happen to cash, checks, and credit card transaction documents? - ANSWER- They must be balanced What will cause a CMS 1500 claim to be rejected? - ANSWER- The provider is billing with a future date of service Under Medicare regulations, which of the following is not included on a valid physician's order for services? - ANSWER- The cost of the test how are HCPCS codes and the appropriate modifiers used? - ANSWER- To report the level 1, 2, or 3 code that correctly describes the service provided If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - ANSWER- Diagnostic and clinically-related non-diagnostic charges provided on the Tuesday, Wednesday, Thursday, and Friday before admission What is a benefit of pre-registering patient's for service? - ANSWER- Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - ANSWER- Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - ANSWER- That the patient's spouse's employer must have less than 20 employees in the group health plan what organization originated the concept of insuring prepaid health care services? - ANSWER- Blue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? - ANSWER- It is acceptable to complete the screening form after the patient has completed the registration process and been sent to the service department If the patient cannot agree to payment arrangements, what is the next option? - ANSWER- Warn the patient that unpaid accounts are placed with collection agencies for further processing In services lines such as cardiology or orthopedics, what does the case-rate payment methodology allow providers to do? - ANSWER- Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? - ANSWER- Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - ANSWER- Code of conduct How does utilization review staff use correct insurance information? - ANSWER- To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - ANSWER- As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - ANSWER- The services will be documented in the wrong record When a patient reports directly to a clinical department for service, what will the clinical department staff do? - ANSWER- Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - ANSWER- Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail How are patient reminder calls used? - ANSWER- To make sure the patient follows the prep instructions and arrives at the scheduled time for service If a patient declares a straight bankruptcy, what must the provider do? - ANSWER- Write off the account to the contractual adjustment account According to the Department of Health and Human Services guidelines, what is NOT considered income? - ANSWER- Sale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - ANSWER- A condition code What are some core elements of a board-approved financial policy - ANSWER- Charity care, payment methods, and installment payment guidelines What circumstance would result in an incorrect nightly room charge? - ANSWER- If the patient's discharge, ordered for tomorrow, has not been charted What is NOT a typical charge master problem that can result in a denial? - ANSWER- Does not include required modifiers Access - ANSWER- An individual's ability to obtain medical services on a timely and financially acceptable level Administrative Services Only (ASO) - ANSWER- Usually contracted administrative services to a self-insured health plan Case management - ANSWER- The process whereby all health-related components of a case are managed by a designated health professional. Intended to ensure continuity of healthcare accessibility and services Claim - ANSWER- A demand by an insured person for the benefits provided by the group contract Coordination of benefits (COB) - ANSWER- a typical insurance provision that determines the responsibility for primary payment when the patient is covered by more than one employer-sponsored health benefit program Discounted fee-for-service - ANSWER- A reimbursement methodology whereby a provider agrees to provide service on a fee for service basis, but the fees are discounted by certain packages Eligibility - ANSWER- Patient status regarding coverage for healthcare insurance benefits First dollar coverage - ANSWER- A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses Gatekeeping - ANSWER- A concept wherein the primary care physician provides all primary patient care and coordinates all diagnostic testing and specialty referrals required for a patient's medical care Health plan - ANSWER- an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - ANSWER- negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary - ANSWER- Healthcare services that are required to preserve or maintain a person's health status in accordance with medical practice standards Out-of-area benefits - ANSWER- healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out-of-pocket payments - ANSWER- Cash payments made by the insured for services not covered by the health insurance plan Pre-admission review - ANSWER- the practice of reviewing requests for inpatient admission before the patient is admitted to ensure that the admission is medically necesary Pre-existing condition limitation - ANSWER- A restriction on payments for charges directly resulting from a pre-existing health conditions Same-day admission - ANSWER- A cost containment practice that reduces a surgical patient's inpatient stay by requiring that pre-procedure testing and preparation are completed on an outpatient basis and the patient is admitted the same day as the procedure Self-insured - ANSWER- Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Subrogation - ANSWER- Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses Subscriber - ANSWER- An employer, a union, or an association that contracts with an insurance company for the healthcare plan it offers to eligible employees Sub-specialist - ANSWER- A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery Third-part administrator (TPA) - ANSWER- Provides services to employers or insurance companies for utilization review, claims payment and benefit design Third-party reimbursement - ANSWER- A general term used for the healthcare benefit payments - used to identify that for benefit plans there are three parties in the transaction Usual, customary, and reasonable (UCR) - ANSWER- Health insurance plan reimbursement methodology that limits payment to the lower billed charges, the provider's customary charge, or the prevailing charge for the service in the community Utilization review - ANSWER- Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Charge - ANSWER- The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Cost - ANSWER- The definition of cost varies by party incurring the expense Price - ANSWER- the total amount a provider expects to be paid by payers and patients for healthcare services Care purchaser - ANSWER- Individual or entity that contributes to the purchase of healthcare services Payer - ANSWER- An organization that negotiates or sets rates for provider services, collects revenue through premium payments or tax dollars, processes provider claims for service, and pays provider claims using collected premium or tax revenues Provider - ANSWER- An entity, organization, or individual that furnishes a healthcare service c) Accounts coded but held within the suspense period d) Accounts assigned to a pre-collection agency - ANSWER- A 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 - ANSWER- C 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 - ANSWER- C 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 - ANSWER- B 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 financial 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 - ANSWER- C 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 - ANSWER- C 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 - ANSWER- B If you need a professional to complete your college homework at a small fee, then reach out to amazingclasshelp.com 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 - ANSWER- A 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 - ANSWER- B 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 - ANSWER- A 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 - ANSWER- A 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 - ANSWER- D 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) 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 - ANSWER- C 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 - ANSWER- A 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 - ANSWER- D 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 - ANSWER- a 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 - ANSWER- A The most common resolution methods for credit balances include all of 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 - ANSWER- A 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 - ANSWER- D If you need a professional to complete your college homework at a small fee, then reach out to amazingclasshelp.com Revenue cycle activities occurring at the point-of-service include all of 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 - ANSWER- C 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 - ANSWER- B 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 - ANSWER- B 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 - ANSWER- B 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 - ANSWER- D Once the price is estimated in the pre-service stage, a provider's financial best practice is to d) Immediately once authorization for treatment is provided by the health plan - ANSWER- A 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 - ANSWER- B 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 - ANSWER- D 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" - ANSWER- D 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 - ANSWER- D 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 - ANSWER- C If you need a professional to complete your college homework at a small fee, then reach out to Homeworkanalyzers.com 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 records is completed so that the proper coding can be initiated - ANSWER- C 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 - ANSWER- D 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. - ANSWER- C 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 - ANSWER- C 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 d) State insurance commissioners - ANSWER- B An advantage of a pre-registration program is a) The opportunity to reduce processing times at the time of service b) The ability to eliminate no-show appointments c) The opportunity to reduce the corporate compliance failures within the registration process d) The marketing value of such a program - ANSWER- C Claims with dates of service received later than one calendar year beyond the date of service, will be a) Denied by Medicare b) The provider's responsibility but can be deemed charity care c) Fully paid with interest d) The full responsibility of the patient. - ANSWER- A This concept encompasses all activities required to send a request for payment to a third-party health plan for payment of benefits a) Third-party invoicing b) Account resolution c) Claims processing d) Billing - ANSWER- C What are some core elements if a board-approved financial assistance policy? a) Payment requirements, staffing hours, and admission policies b) Case management, payment methods, and discharge policies c) Deposit requirements, pre-registration calling hours, and charity care policy d) Eligibility, application process, and nonpayment collection activities - ANSWER- D The ICD-10 codes set and CPT/HCPCS code sets combines provide a) Pricing floors for services b) The financial data required for activity-based costing c) Patients an overview of services covered by their health insurance plan d) The specificity and coding needed to support reimbursement claims - ANSWER- D A recurring/series registration is characterized by a) A creation of multiple registrations for multiple services b) The creation of one registration record for multiple days of service c) The creation of multiple patient types for one date of service d) The creation of one registration record per diagnosis per visit - ANSWER- B 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? a) Complete course of treatment b) Medical screening and stabilizing treatment c) Admission to observation status d) Transfer to another facility - ANSWER- B In resolving medical accounts, a law firm may be used as: a) An independent auditor of a financial assistance policy b) Legal counsel to patients regarding financing options c) An independent broker of patient financial assistance from banks d) A substitute for a collection agency - ANSWER- D The unscheduled "direct" admission represents a patient who: a) Is admitted from a physician's office on an urgent basis b) Arrives at the hospital via ambulance for treatment in the emergency room c) Is an ambulatory patient who collapses in the hospital lobby d) Arrives on the medical helicopter for trauma services - ANSWER- A In the balance resolution process, providers should: a) Stress to the patient that serious consequences may result from refusal to pay b) Remind the patient of their legal responsibility to pay the balance due c) Ask the patient if he or she would like to receive information about payment options and supportive financial assistance programs d) Tag the patients record for possible financial assistance for bad debt - ANSWER- C Which of the following in NOT included in the Standardized Quality Measures a) Clinical outcomes b) Patient perceptions c) Health care processes d) Cost of services - ANSWER- D In the pre-service stage, the requested service is screened for medical necessity, health plan coverage and benefits are verified and: a) Billing authorization is signed by the patient b) The patient signs the consents for treatment c) The patient signs a statement attesting an understanding and acceptance of payment policies d) Pre-authorization are obtained - ANSWER- D Improving the overall patient experience requires revenue cycle leadership and staff to simultaneously be: a) Clear on policies and consistent in applying the policies b) Careful in screening patient demands c) Monitoring the costs and charges the patient incurs d) Inquisitive, responsive and flexible - ANSWER- A Hospitals need which of the following information sets to assess a patient's financial status: a) Income, expenses, debt b) Patient and guarantor's income, expenses and assets c) Income, expenses and capacity to take on more debt d) Assets liquidity, Income, expenses, credit worthiness - ANSWER- B For scheduled patients, important revenue cycle activities I the Time of Service stage DO NOT INCLUDE: a) Pre-registration record is activated, consents are signed, and co-payment is collected b) Positive patient identification is completed, and patient is given an armband c) Final bill is presented for payment d) Preprocessed patients may report to a designated "express arrival" desk - ANSWER- C The Electronic Remittance Advice (ERA) data set is : a) Used for Electronic Funds Transfers between hospitals and a bank b) A standardized form that provides 3rd party payment details to providers c) Required for annual Medicare quality reporting forms d) Safeguards the Electronic claims process - ANSWER- B Appropriate training for patient financial counseling staff must cover all of the following EXCEPT: a) Patient financial communications best practices specific to staff role b) Financial assistance policies c) Documenting the conversation in the medical records d) Available patient financing options - ANSWER- C All of the following information should be reviewed as part of schedule finalization EXCEPT: a) The results of any and all test b) The service to be provided c) The arrival time and procedure time d) The patient's preparation instructions - ANSWER- A Indemnity plans usually reimburse: a) Only for contracted Services c) CPT codes d) Revenue codes - ANSWER- D The importance of Medical records being maintained by HIM is that the patient records: a) Are evidence used in assessing the quality of care b) Are the primary source for clinical data required for reimbursement by health plans and liability payers C) Are the strongest evidence and defense in the event of a Medicare Audit d) Are the evidence cited in quality review - ANSWER- B Medicare patients are NOT required to produce a physician order to receive which of these services a) Diagnostic Mammography, flu vaccine, or B-12 shots b) Diagnostic Mammography, flu vaccine, or pneumonia vaccine c) Screening Mammography, flu vaccine or pneumonia vaccine d) Screening Mammography, flu vaccine or B-12 shots - ANSWER- C Patients should be informed that costs presented in a price estimate may a) Vary from estimates, depending on the actual services performed b) Be guaranteed if the patient satisfies all patient financial responsibilities at the time of registration c) Be lower as price estimates use the highest market price d) Only determine the percentage of the total that the patient is responsible for and not the actual cost - ANSWER- A Ambulance services are billed directly to the health plan for a) All pre-admission emergency transports b) Transport deemed medically necessary by the attending paramedic-ambulance crew c) 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 d) The portion of the bill outside of the patient's self-pay - ANSWER- C In Chapter 7 straight bankruptcy filling a) The court establishes a creditor payment schedule with the longest outstanding claims paid first b) The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt 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 liquidates the debtor's nonexempt property, pays creditors, and begins to pay off the largest claims first. All claims are paid some portions of the amount owed. - ANSWER- B The activity which results in the accurate recording of patient bed and level of care assessment, patient transfer and patient discharge status on a real-time basis is known as a) Utilization review b) Case management c) Census management d) Patient through-put - ANSWER- B Which of the following is required for participation in Medicaid a) Obtain a supplemental health insurance policy b) Meet income and assets requirements c) Meet a minimum yearly premium d) Be free of chronic conditions - ANSWER- B When primary payment is received, the actual reimbursement a) Is compared to the expected reimbursement b) Is recorded by Patient Accounting and the patient's account is the closed c) Is compared to the expected reimbursement, the remaining contractual adjustments are posted, and secondary claims are submitted d) Trigger that the secondary claims can then be prepared. - ANSWER- C Days in A/R is calculated based on the value of a) Total cash received to date b) The time it takes to collect anticipated revenue c) The total accounts receivable on a specific date d) Total anticipated revenue minus expenses - ANSWER- C e) If you need a professional to complete your college homework at a small fee, then reach out to Homeworkanalyzers.com All of the following are forms of hospital payment contracting EXCEPT a) Per diem payment b) Bundled Payment c) Fixed Contracting d) Contracted Rebating - ANSWER- D The standard claim form used for billing by hospitals, nursing facilities, and other in- patient services is called the a) UB-04 b) 1500 c) COST REPORT d) REMITTANCE NOTICE - ANSWER- A To maximize the value derived from customer complaints, all consumer complaints should be a) Responded to within two business days b) Tracked and shared to improve the customer experience c) Handled by a specially trained "service recovery" team d) Brought immediately to management's attention - ANSWER- A The HCAHPS (hospital consumer assessment of healthcare providers and systems) initiative was launched to a) Gather national date on overall trust in the nation's health care system b) Create a national database on physician quality c) Provide a standardized method for evaluating patient's perspective on hospital care. ? d) Provide data for building shared savings reimbursement for quality procedures. - ANSWER- C Health Plan Contracting Departments do all of the following EXCEPT a) Establish a global reimbursement rate to use with all third-party payer b) Review all managed care contracts for accuracy for loading contract terms into the Successful account resolution begins with a) Educating pts on their estimated financial responsibility b) Collecting all deductibles and copayments during the pre-service stage c) Accurate documentation of services d) Pt compliance with the course of treatment - ANSWER- B 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 medicare determination appeal b) A payment review c) A medicare supplemental review d) A beneficiary appeal - ANSWER- D A portion of the accounts receivable inventory which has NOT qualified for billing includes a) Charitable pledges b) Accounts assigned to a pre-collection agency c) Accounts coded but held within the suspense period d) Accounts created during pre-registration but not activated - ANSWER- A Checks received through mail, cash received through mail, and lock box are all examples of a) Highly fraud prone processes b) Payment methods in which the majority of fraud occurs c) Payment methods being phased out for more secure payment method options d) Control points for cash posting - ANSWER- D Recognizing that health coverage is complicated and not all pts are able to navigate this terrain, HFMA best practices specify that a) A representative of the health plan be included in the pt financial responsibilities discussion b) The patient accounts staff have someone assigned to research coverage on behalf of pts c) Pts should be given the opportunity to request a pt advocate, family member or other designee to help them In these discussions d) Pt coverage education may need to be provided by the health plan - ANSWER- C Once the price is estimated in the pre-service stage, a provider's financial best practice is to a) Allow the pt time to compare prices with other providers b) Have another employee double check the price estimate c) Lock-in the prices d) Explain to the pt their financial responsibility and to determine the plan for payment - ANSWER- D Charges as the most appropriate measurement of utilization enables a) Accuracy of expense and cost capture b) Managing of expense budgets c) Effective HIM planning d) Generation of timely and accurate billing - ANSWER- A 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) HMO b) PPO c) MSO d) GPO - ANSWER- A Charges are the basis for a) Third party and regulatory review of resources used b) Evaluating quality c) Separation of fiscal responsibilities between the pt and the health plan d) Demonstrating medical necessity - ANSWER- C Chapter 13 Bankruptcy, debtor rehabilitation is a court proceeding a) That reorganizes a debtor's holdings and instructs creditors to look to the debtors' future earnings for payment b) That establishes a payment priority order to creditos' c) That creates a clear court-supervised payment accountability plan going forward d) That classifies the debtor as eligible for government financial assistance for housing medical treatment and food as debts are paid - ANSWER- A Pt financial communications best practices produce communications that are a) Timely and remind pts of their financial responsibilities b) Consistent, clear and transparent c) Current and report the status of a pts claim d) Timely, comprehensive and specifying next steps - ANSWER- B Key performance indicators (KPIs) set standards for accounts receivables (A/R) and a) Establish productivity targets b) Provide a method of measuring the collection and control of A/R c) Provide evidence of financial status d) Make allowance for accurate revenue forecasting - ANSWER- B If you need a professional to complete your college homework at a small fee, then reach out to Homeworkanalyzers.com When Recovery Audit Contractors (RAC) identify improper payments as over payments, the claims processing contractor must a) Assume legal responsibility for repaying the overage amount b) Make recovery of the overpayment the top processing priority c) Send a demand letter to the provider to recover the over payment amount d) Conduct an audit of all the effected providers claims within the past twelve months - ANSWER- C A recurring/series registration is characterized by a) The creation of one registration record for multiple days of service b) The creation of multiple registrations for multiple services c) The creation of one registration record per diagnosis per visits d) The creation of multiple pt types for one date of service - ANSWER- A It is important to have high registration quality standards because a) Inaccurate or incomplete pt data will delay payment or cause denials b) Incomplete registrations will trigger exclusion from Medicare participation c) Inaccurate registration may cause discharge before full treatment is obtained d) Incomplete registrations will raise satisfaction scores for the hospital - ANSWER- A d) Banking transaction errors - ANSWER- A Across all care settings, if a pt consents to a financial discussion during a medical encounter to expedite discharge, the HFMA best practice is to a) Have a pt financial responsibilities kit ready for the pt containing all of the required registration forms and instructions b) Make sure that the attending staff can answer questions and assist in obtaining required pt financial data c) Support that choice, providing that the discussion does not interfere with pt care or disrupt pt flow d) Decline such request as finance discussions can disrupt pt care and pt flow - ANSWER- C The office of inspector general (OIG) publishes a compliance work plan a) Monthly b) Quarterly c) Semi-annually d) Annually - ANSWER- D What are collection agency fees based on? - ANSWER- A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - ANSWER- Birthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - ANSWER- Case rates What customer service improvements might improve the patient accounts department? - ANSWER- Holding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - ANSWER- Inform a Medicare beneficiary that Medicare may not pay for the order or service What type of account adjustment results from the patient's unwillingness to pay for a self-pay balance? - ANSWER- Bad debt adjustment What is the initial hospice benefit? - ANSWER- Two 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - ANSWER- If the patient requires ambulance transportation to a skilled nursing facility How should a provider resolve a late-charge credit posted after an account is billed? - 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 - ANSWER- They are not being processed in a timely manner What is an advantage of a preregistration program? - ANSWER- It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - ANSWER- Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - ANSWER- Scheduling, insurance verification, discharge processing, and payment of point-of- service receipts What statement applies to the scheduled outpatient? - ANSWER- The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - 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 patient's need for inpatient care? - ANSWER- Observation - If you need a professional to complete your college homework at a small fee, then reach out to Homeworkanalyzers.com Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - 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 Field 0$? - ANSWER- When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - ANSWER- Unscheduled patients If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - 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? - ANSWER- Disclosure rules for consumer credit sales and consumer loans What is a principal diagnosis? - ANSWER- Primary reason for the patient's admission Collecting patient liability dollars after service leads to what? - ANSWER- Lower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - ANSWER- 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 services? - ANSWER- Inpatient care What code indicates the disposition of the patient at the conclusion of service? - ANSWER- Patient discharge status code What are hospitals required to do for Medicare credit balance accounts? - ANSWER- 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? - ANSWER- Patient Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: - ANSWER- A valid CPT or HCPCS code What will cause a CMS 1500 claim to be rejected? - ANSWER- The provider is billing with a future date of service Under Medicare regulations, which of the following is not included on a valid physician's order for services? - ANSWER- The cost of the test how are HCPCS codes and the appropriate modifiers used? - ANSWER- To report the level 1, 2, or 3 code that correctly describes the service provided If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - ANSWER- Diagnostic and clinically-related non-diagnostic charges provided on the Tuesday, Wednesday, Thursday, and Friday before admission What is a benefit of pre-registering patient's for service? - ANSWER- Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? - ANSWER- Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - ANSWER- That the patient's spouse's employer must have less than 20 employees in the group health plan what organization originated the concept of insuring prepaid health care services? - ANSWER- Blue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? - ANSWER- It is acceptable to complete the screening form after the patient has completed the registration process and been sent to the service department If the patient cannot agree to payment arrangements, what is the next option? - ANSWER- Warn the patient that unpaid accounts are placed with collection agencies for further processing In services lines such as cardiology or orthopedics, what does the case-rate payment methodology allow providers to do? - ANSWER- Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? - ANSWER- Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? - ANSWER- Code of conduct How does utilization review staff use correct insurance information? - ANSWER- To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - ANSWER- As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - ANSWER- The services will be documented in the wrong record When a patient reports directly to a clinical department for service, what will the clinical department staff do? - ANSWER- Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - ANSWER- Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail How are patient reminder calls used? - ANSWER- To make sure the patient follows the prep instructions and arrives at the scheduled time for service If a patient declares a straight bankruptcy, what must the provider do? - ANSWER- Write off the account to the contractual adjustment account According to the Department of Health and Human Services guidelines, what is NOT considered income? - ANSWER- Sale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - ANSWER- A condition code What option is an alternative to valid long-term payment plans? - ANSWER- Bank loans What is an advantage of using a collection agency to collect delinquent patient accounts? - ANSWER- Collection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? - ANSWER- revenue codes identify the payer When a patient's illness results in an unusually high amount of medical bills not covered by insurance or other patient pay resources, what type of account is created - ANSWER- catastrophic charity What happens when a patient receives non-emergent services from and out-of- network provider? - ANSWER- Patient payment responsibility is higher Every patient who is new to the healthcare provider must be offered what? - ANSWER- A printed copy of the provider's privacy notice How may a collection agency demonstrate its performance? - ANSWER- Calculate the rate of recovery What is true of the information the provider supplies to indicate that an authorization for service has been received from the patient's primary payer? - ANSWER- It is posted on the remittance advice by the payer What standard claim forms are currently used by the healthcare industry to submit claims to third-party payers? - ANSWER- The UB-04 and the CMS 1500 Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information? - ANSWER- Obtain the required demographic and insurance information before services are rendered what protocol was developed through the Patient Friendly Billing Project? - ANSWER- Provide information using language that is easily understood by the average reader What technique is acceptable way to complete the MSP screening for a facility situation? - ANSWER- Ask if the patient's current services was accident related What is a valid reason for a payer to delay a claim? - ANSWER- Failure to complete authorization requirements IF outpatient diagnostic services are provided within three days of the admission of a Medicare beneficiary to an IPPS (Inpatient Prospective Payment System) Medically necessary - ANSWER- Healthcare services that are required to preserve or maintain a person's health status in accordance with medical practice standards Out-of-area benefits - ANSWER- healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out-of-pocket payments - ANSWER- Cash payments made by the insured for services not covered by the health insurance plan Pre-admission review - ANSWER- the practice of reviewing requests for inpatient admission before the patient is admitted to ensure that the admission is medically necesary Pre-existing condition limitation - ANSWER- A restriction on payments for charges directly resulting from a pre-existing health conditions Same-day admission - ANSWER- A cost containment practice that reduces a surgical patient's inpatient stay by requiring that pre-procedure testing and preparation are completed on an outpatient basis and the patient is admitted the same day as the procedure Self-insured - ANSWER- Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Subrogation - ANSWER- Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses Subscriber - ANSWER- An employer, a union, or an association that contracts with an insurance company for the healthcare plan it offers to eligible employees Sub-specialist - ANSWER- A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery Third-part administrator (TPA) - ANSWER- Provides services to employers or insurance companies for utilization review, claims payment and benefit design Third-party reimbursement - ANSWER- A general term used for the healthcare benefit payments - used to identify that for benefit plans there are three parties in the transaction Usual, customary, and reasonable (UCR) - ANSWER- Health insurance plan reimbursement methodology that limits payment to the lower billed charges, the provider's customary charge, or the prevailing charge for the service in the community Utilization review - ANSWER- Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Charge - ANSWER- The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Cost - ANSWER- The definition of cost varies by party incurring the expense Price - ANSWER- the total amount a provider expects to be paid by payers and patients for healthcare services Care purchaser - ANSWER- Individual or entity that contributes to the purchase of healthcare services Payer - ANSWER- An organization that negotiates or sets rates for provider services, collects revenue through premium payments or tax dollars, processes provider claims for service, and pays provider claims using collected premium or tax revenues Provider - ANSWER- An entity, organization, or individual that furnishes a healthcare service Out of pocket payment - ANSWER- The portion of the total payment for medical services and treatment for which the patient is responsible, including copayments, coinsurance, and deductibles Price transparency - ANSWER- In health care, readily available information on the price of healthcare services that, together, with other information helps define the value of those services and enables patients and other care purchasers to identify, compare, and choose providers that offer the desired level of value Value - ANSWER- The quality of a healthcare service in relation to the total price paid for the service by care purchasers What areas does the code of conduct typically focus on? - ANSWER- Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations FERA - ANSWER- Fraud Enforcement and Recovery act ESRD - ANSWER- End-stage renal disease. The patient has permanent kidney failure, is covered by a GHP, and has not yet completed the 30-month coordination period What is the purpose of a compliance program? - ANSWER- Mitigate potential fraud and abuse in the industry-specific key risk areas What is important about an effective corporate compliance program? - ANSWER- A program that embodies many elements to create a program that is transparent, clearly articulated and emphasized at all employee levels as a seriously held personal and organizational responsibility, one that relies on full communication inside and outside the organization What is a CCO - ANSWER- Chief compliance officer - they typically report directly to the board of directors/trustees as well as the chief executive officer, and has limited responsibilities for other operational aspects of the organization What are the situations where another payer may be completely responsible for payment? - ANSWER- Work-related accidents, black lung program services, patient is enrolled in Medicare Advantage, Federal grant programs Under Medicare rules, certain outpatient services that are provided within three days of the admission date, by hospitals or by entities owned or controlled by hospitals, must be billed as part of an inpatient stay. - ANSWER- TRUE The OIG has issued compliance guidance/model compliance plans for all of the following entities: - ANSWER- hospices. physician practices. ambulance providers Providers who are found to be in violation of CMS regulations are subject to: - ANSWER- Corporate integrity agreements D. The focus is on the patient and his/her financial care, in addition to the clinical care provided for the patient. The following statements describe best practices established by the Medical Debt Task Force. Check the box next to the True statements - ANSWER- **Educate Patients **Coordinate to avoid duplicate patient contacts Exercise moderate judgement when communicating with providers about scheduled services **Be consistent in key aspects of account resolution Report to healthcare plans when the patient's account is transferred to collection agency **Follow best practices for communication Which option is NOT a main HFMA Healthcare Dollars & Sense® revenue cycle initiative? - ANSWER- A. Patient Financial Communications B. Price Transparency C. Medical Account Resolution **D. Process Compliance What is the objective of the HCAHPS initiative? - ANSWER- **A. To provide a standardized method for evaluating patients' perspective on hospital care. B. To provide clear communication and good customer service, which will give the provider a competitive edge. C. To conduct evaluations concerning patients' perspective on hospital care. D. To make certain that during registration key information is verified by means of a picture ID and an insurance card. Which option is NOT a department that supports and collaborates with the revenue cycle? - ANSWER- A. Information Technology B. Clinical Services C. Finance **D. Assisted Living Services Which option is NOT a continuum of care provider? - ANSWER- A. Physician **B. Health Plan Contracting C. Hospice D. Skilled Nursing Facility Which of the following are essential elements of an effective compliance program? - ANSWER- **Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines **Established compliance standards and procedures Automatic dismissal of any employee excluded from participation in a federal healthcare program **Designation of a compliance officer employed within the Billing Department **Oversight of personnel by high-level personnel. Annually, the OIG publishes a work plan of compliance issues and objectives that will be focused on throughout the following year. Identify which option is NOT a work plan task mentioned in this course. - ANSWER- A. Payments to Physicians for Co-Surgery Procedures B. Denials and Appeals in Medicare Part D C. Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute- Care Transfer Policies **D. Standard Unique Employer Identifier In order to promote the use of correct coding methods on a national basis and prevent payment errors due to improper coding, CMS developed what? - ANSWER- **A. The Correct Coding Initiative (CCI) B. The Advance Beneficiary Notice of Noncoverage (ABN) C. The Medicare Secondary Payer (MSP) D. Modifiers Indicate if the activity is described by the appropriate description of the violation involved: - ANSWER- True - A staff member receives cash in the mail and does not immediately report the case to the manager for special handling. This is an example of financial misconduct False - A mother sees a charge on her hospital bill for a circumcision for a newborn girl. This is an example of falsifying medical records to boost reimbursement. True - A patient access staff member takes several file folders and highlighters home for personal use. This is an example of theft of property. False - A physician documents a fictitious epidural in a patient's medical record in an effort to receive additional payment. This is an example of miscoding claims True - Several unauthorized claims are sent to a health plan with the wrong procedure code. This is an example of overcharging. What do business/organizational ethics represent? - ANSWER- **A. Principles and standards by which organizations operate B. A healthcare provider's practices and principles C. An employee's actions influenced by experiences and value system D. The patient privacy standard within healthcare What is the intended outcome of collaborations made through an ACO delivery system? - ANSWER- **A. To ensure appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients. B. To create cost-containment provisions to reform the healthcare delivery system. C. To reform the healthcare system into a system that rewards greater value, improves the quality of care and increases efficiency in the delivery of services. D. To provide financial incentives to physicians for reporting quality data to CMS. Which of these statements describes the new methodology for the determination of net patient service revenue: - ANSWER- A. Net patient service revenue is defined as the average payment amount for the payer but not recorded until the end of the month processing is completed. B. Gross patient service revenue is recorded as net patient service revenue until such time as all payments are received. **C. Net patient service revenue is defined as the total incurred charges, less the explicit price concession, less any applicable implicit price concession(s) as applied to the specific portfolio of accounts. D. Net patient service revenue is gross revenue minus any contractual adjustments applicable to the account. Any additional adjustments are not recorded until the account reaches a zero balance. Which option is NOT a specific managed care requirement? - ANSWER- A. Referrals B. Notification **C. Preferred Provider Organization D. Discharge Planning What is the first component of a pricing determination? - ANSWER- A. Identify the service or test involved **B. Verification of the patient's insurance eligibility and benefits C. Inform the patient that physician services are or are not included D. Use a worksheet or other tool for guidance in determining an estimate The correct sequential order of the financial counseling steps for an uninsured patient's surgery case are: - ANSWER- Greet patient and give your name Explain organization's financial care approach and patient's financial responsibility Review patient's health plan benefits and status Review anticipated charges and patient's anticipated liability Ask patient to resolve liability by reviewing payment options For uninsured, explain financial assistance options What is the purpose of financial counseling? - ANSWER- A. To address the most appropriate ways to conduct financial interactions at every point B. To train staff on how to request payment and conduct conversations **C. To educate the patient on his/her health plan coverage and financial responsibility for healthcare services D. To help the patient understand exactly how a contracted health plan will resolve their benefit package EMTALA prohibits inquiries about health plan or liability payer information if the inquiry will delay examination or treatment. What other requirements apply to the Emergency Department registration work? - ANSWER- ALL of the above Typical activities which much be performed when an unscheduled patient arrives for service include: - ANSWER- Identification of patient in the MPI or initiation of a new MPI record, insurance verification of eligibility and benefits, managed care screening, medical necessity screening, price estimation and financial counseling to achieve the appropriate account resolution. Case managers are involved from admission with the discharge planning process. The purpose of discharge planning is: - ANSWER- To estimate how long the patient will be in the hospital, identify the expected outcome of the hospitalization and initiate any special requirements for services at or after the time of discharge. The chargemaster is basically a list of services, procedures, room accommodations, supplies, drugs, tests, etc. typically associated with the billing for services rendered to patients. Challenges typically associated with the billing for services rendered to patients. Challenges typically associated with the chargemaster include: - ANSWER- Omission of charges, obsolete or invalid codes, and the omission of required modifiers. Ultimately, the services provided in the healthcare system are reduced to standard codes. The primary types of coding systems currently used in healthcare are: - ANSWER- ICD-10-CM/ICD-10-PCS; CPT/HCPCS codes There are four code sets that provide health plans with additional information as they process claims. Those code sets are: - ANSWER- Condition codes, occurrence codes, occurrence span codes and value codes Each type of service has unique billing rules which come into play during the provision of service. For the skilled nursing facility, care is covered if which of the following factors are present: - ANSWER- The patient required skilled services on a daily basis and those services can only be provided on an inpatient basis in a SNF. DRG's are a system of classifying inpatients on the basis of diagnoses, procedures, and co-morbidities for purposes of payment to hospitals. Each DRG includes: - ANSWER- A relative weight which is multiplied by the established base payment rate to calculate the reimbursement for a specific DRG. For exceptionally costly cases over a set dollar amount, an outlier payment is added to the calculated payment. PPO networks represent one form of discounting commonly used by commercial payers. The silent PPO represents: - ANSWER- A discounting scheme whereby health plans apply generic PPO rates to discount a provider's claims, even though there is no contractual arrangement between the silent PPO and the provider. The concept of timely filing of claims is important to providers, payers and patients. Thus, providers are required to comply with timely claim filing rules. Which of the following statements are NOT true about timely filing limitations: - ANSWER- Payers will waive timely filing denials for claims filed over a year from date of service. What does EMTALA require hospitals to do? - ANSWER- **A. To provide a medical screening examination and stabilizing treatment to every person presenting at an ED and requesting medical evaluation or treatment. B. To initially triage patients, where a "quick" registration record is generated to specifically allow order entry. C. To complete a standardized form signed by all patients that is used to inform the patient about the admission and conditions which must be agreed upon. D. To confirm information that may be used to identify the patient in the provider's MPI, which includes the patient's full, legal name, SSN, and/or date of birth. In what manner do case managers assist revenue cycle staff? - ANSWER- A. By reviewing a patient's individual case and recommend treatment changes. B. With monitoring the progression of high resource consumptive cases. C. By estimating how long the patient will be in the hospital and what the expected outcome will be. **D. Providing assistance with written appeals to health plans related to utilization and other care issues. Why is it critical that a chargemaster is reviewed and updated regularly? - ANSWER- **A. To ensure it supports and represents the services provided within the organization. B. To ensure the most appropriate measure of the utilization of resources. C. So the CPT databases can have the most current and accurate information. D. Because charge descriptions can vary greatly between providers. What is the responsibility of HIM? - ANSWER- **A. To maintain all patient medical records B. To make information available instantly and securely to authorized users C. To denote the medical procedures performed by a healthcare provider on a patient D. To substantiate health insurance claims filed by the patient, the physician, and the provider The three types of bankruptcy as defined in the 1979 Bankruptcy Act are: - ANSWER- Chapter 7 - Straight Bankruptcy, Chapter 11- Debtor Reorganization and Chapter 13- Debtor Rehabilitation Which of the following medical debt collection practices are recommended as part of HFMA's Best Practices for medical account resolution: - ANSWER- Establish policies and ensure that they are followed Organizations may opt to contract with or outsource to specific vendors for some or all components of revenue cycle processing. This practice has both advantages and disadvantages. Which of the following statements is NOT an advantage of utilizing an outsourcing vendor? - ANSWER- The need for legal review if the outside vendor's staff represents themselves as employees of the healthcare facility. Each hospital covered by the 501(r) regulations is required to develop a financial assistance policy. Which of the following elements is NOT a required element of the policy? - ANSWER- The notice that individuals eligible for financial assistance under this policy may be charged more that the amount generally billed (AGB) to insured patients. Place the daily reconciliation process steps in the correct sequential order: - ANSWER- Obtain totals of all payments - cash, check, credit card, and debit card Divide remittances into batches and obtain a second total of the electronic remittance advices by payment and contractual allowances Endorse checks immediately. Prepare the bank deposit for all payments. Separate cash payments and contractual adjustments into separate batches and use separate payments and adjustment codes. Post unidentified payments to an unidentified cash account (deposit everything, do not hold unidentified payments) Balance and post batches. Balance payments to the bank deposit. Balance the bank deposit to the general ledger. Sue Smith came into the hospital. Her insurance provider sent an EFT directly into the hospital's account at the bank. John, the hospital representative, receives an electronic Level 2 ERA. What should he do next? - ANSWER- **A. Manually match the ERA to the patient account. B. Nothing unless there is an error. What is EFT? - ANSWER- **A. The electronic transfer of funds from payer to payee through the banking system. B. The establishment of internal audits by personnel outside the involved department. C. A standardized healthcare claim payment/advice known as the 835 format. D. A process that requires the separation of duties when processing patient payments. Which statement is false regarding credit balances? - ANSWER- A. A small credit policy should be matched by a similar policy for small debit balances. B. Tracking reports should be developed to identify internal charge credits versus external charge credits. C. Hospital generated statements should be sent to patients regarding small credit balances. **D. There are no CMS hospital compliance requirements regarding credit balances. If you need a professional to complete your college homework at a small fee, then reach out to Datedhomeworks.com Which option is NOT a type of denial? - ANSWER- A. Technical B. Clinical C. Underpayment **D. Contractual Adjustment Which option is NOT a lien type? - ANSWER- A. Judicial **B. Subrogation C. Statutory D. Agreement (Consensus) Based on what you have just read, which activity is not considered when initiating self-pay follow-up and account resolution activities? - ANSWER- A. Poverty Guidelines B. Financial Profile C. Presumptive Financial Assistance Determination **D. Patient Open Balance Billing Which option is NOT a required component of a FAP? - ANSWER- A. Eligibility criteria B. Application process C. Application assistance **D. Out-of-network providers Which option is NOT a bankruptcy type governed by the 1979 Bankruptcy Act? - ANSWER- A. Straight bankruptcy B. Debtor reorganization **C. Creditor priority D. Debtor rehabilitation Which evaluation criteria demonstrates reputation expectations: - ANSWER- A. The agency's Yelp score and consumer comments. B. The amount of monies collected monthly. **C. The employment of staff who have documented experience working in financial areas of health care. D. The high turnover rate for entry level employees. Agency fees are: - ANSWER- A. Paid by patients. **B. The cost to the provider for collection agency monies offset by the return on baddebt accounts. C. Only reported annually to the provider. D. Waived for accounts aged greater than one year from date of service. The correct way to handle the retention and payment of agency fees is: - ANSWER- A. The agency provides an annual settlement of monies received by the health care provider and the agency. B. Compare estimated collection costs to actual costs incurred. C. Validate bank deposits weekly as funds are received from the agency. **D. Follow the contractual agreement between the agency and the provider as to how monies sent to the agency will be handled. Patient relations include: - ANSWER- **A. The ability to sensitively deal with patients or individuals while managing collection efficiency. B. Applying hard-core techniques to collect monies owed regardless of what the patient or individual states during the call. C. Ignoring all patient complaint calls. D. Referring all patient complaint calls to the healthcare provider. Collection agency reports should be provided: - ANSWER- A. Whenever staff have the time to generate them.