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CRCR 2025 TEST BANK FINAL EXAM QUESTIONS &
DETAILED ANSWERS (WELL VERIFIED) GRADED A+
What do Case Managers do? - CORRECT ANSWER >>> Monitor high resource cases to ensure effective utilization What is HIM responsible for? - CORRECT ANSWER >>> all pt medical records: transcribe, coding, release to biling, answer requests for documentation What is utilization management responsible for? - CORRECT ANSWER >>> manage cases: services correct, on time What are the three types of utilization review? - CORRECT ANSWER >>> Prospective, Concurrent, Retrospective Where can home health services be offered? - CORRECT ANSWER >>> Home, Assist Living, neighbors: just not SNF nor Hospital To receive - Care payments, what must a SNF have when receiving a pt from a hosp? - CORRECT ANSWER >>> A transfer agreement approved by - Care. Can a home health agency employ another agency to provide services? **- CORRECT ANSWER
** Yes, so long as at least one employee of the original agency provides care. What is the Net Collection Rate? - CORRECT ANSWER >>> how much cash was collected as a % of available to collect? What is the Net Collection Rate benchmark? - CORRECT ANSWER >>> 95%
What is the benchmark for denials - CORRECT ANSWER >>> <2% on first submission Formual for cost to collect - CORRECT ANSWER >>> total PFS expenses/gross pt care collections What is the benchmark for cost to collect - CORRECT ANSWER >>> 2.25% What % of the UB-04 source of data is from pt access? - CORRECT ANSWER >>> 40% What % of the UB-04 source of data is from service depts? - CORRECT ANSWER >>> 11% What % of the UB-04 source of data is from HIM? - CORRECT ANSWER >>> 20% What % of the UB-04 source of data is from billing? - CORRECT ANSWER >>> 20% What % of the UB-04 source of data is not used? - CORRECT ANSWER >>> 9% What % of the CMS 1500 source of data is from pt access? - CORRECT ANSWER >>> 53% What % of the CMS 1500 source of data is from service? - CORRECT ANSWER >>> 14% What % of the CMS 1500 source of data is from HIM - CORRECT ANSWER >>> 7% What % of the CMS 1500 source of data is from billing? - CORRECT ANSWER >>> 26%
What are the three types of pt access incoming to a HCO? - CORRECT ANSWER >>> scheduled, unscheduled, recurring What is LCD - CORRECT ANSWER >>> local coverage determinants, in absence of NCD, LCD dtermines whether - Care will pay for an item or service What is NCD - CORRECT ANSWER >>> national coverage determinants:' nationwide determination of whether Medicare will pay for an item or service What % of pts should be pre-registered of all scheduled pts? - CORRECT ANSWER >>> 98% What is the code for HIPAA transaction set for HC eligibility and benefit responses - CORRECT ANSWER >>> 270 outgoing 271 response What are some payer data elements needed to process payment? **- CORRECT ANSWER
** policy type, covered persons, mail address, cvr type (HMO), deductible What is an PPO - CORRECT ANSWER >>> closest to indemnity plan, only preferred doctors in network get contracted prices What is an EPO - CORRECT ANSWER >>> exclusive provider - limits services to only EP What is POS - CORRECT ANSWER >>> point of service - if doc makes referral out, plan will pay, if pt requests out of service, pt pays What is CDHP - CORRECT ANSWER >>> consumer directed healthplan, often with a HSA
What is the % discount model in MCO - CORRECT ANSWER >>> a % is discounted What is the DRG model in MCO - CORRECT ANSWER >>> pymt based on predetermined fixed amount What is the APG model in MCO - CORRECT ANSWER >>> divides outpt services into 600 procedural groups, each APG assigned a relative payment weight What is a case rate - CORRECT ANSWER >>> pt's condition forms basis for payment for all services What is stop loss - CORRECT ANSWER >>> plan covers 80% of charges to 100%, stop loss is plan covers 50% of charges >$120k What are some managed care requirments? - CORRECT ANSWER >>> pre- certification/preauthorization, referral (PCP->specialist), notification - providers notify payer pt is requesting service, days approval, continued stay review, site of service limitations (eg only colonosco as outpt) What are some concerns with EMTALA - CORRECT ANSWER >>> sign posted on walls, no prior authorization, women in active labor must be assisted thru delivery, on-call MD must respond, no dumping, no transfer (unless cannot provide service), must do mental health screening, must keep pt log What is the referring MD - CORRECT ANSWER >>> the one to referred to another MD What is the attending MD - CORRECT ANSWER >>> One who wrote order for service
Can - Care be billed after billing a liability payer? - CORRECT ANSWER >>> yes, after 120 days. Must release liability and - Care will pursue liability payer What are typical claim edits? - CORRECT ANSWER >>> medical necessity, invalid demo info, invalid codes, missing NPI #s Name three aspects to the Hospital Readmit Reduction Act - CORRECT ANSWER >>> CMS reduces pymt to hosp w/ excessively high readmit for heart, COPD, pneumonia, knee replace; also to MDs who do not report qual data Why is the charge master imptt even in managed care? - CORRECT ANSWER >>> reimbursemt based on % of charges or stop loss based on total What are the two components of the charge master - CORRECT ANSWER >>> room and board (by nursing unit, room type) and ancillary charges - will list UB-04 rev code, CPT/HCPCS code and charge amount What are level 1 CPT codes - CORRECT ANSWER >>> five numbers (for procedures) What are level 2 CPT codes - CORRECT ANSWER >>> for supplies, ambulance (alpha and 4 digits) What are level 3 CPT codes - CORRECT ANSWER >>> not common What are level 1 CPT modifiers - CORRECT ANSWER >>> eg would be 23 - unusual anesthesia What are level 11 CPT modifiers - CORRECT ANSWER >>> eg: LT - left side, E4 - lower right eyelid What are level III CPT modifiers - CORRECT ANSWER >>> XI - FDA approved drug
Is there a chain to modifiers? - CORRECT ANSWER >>> Yes, a HCPCS level III has higher precedence than a HCPCS NP level II for example In Pay for Performance, what do hospitals do in the Hosp Qual Initiative? **- CORRECT ANSWER
** hosp must submit data about 10 quality measures In Pay for Performance, what must hospitals do in the Premier Hosp Quality initiative? - CORRECT ANSWER >>> If hosp score in top 10%, receive a 2% bonus, if not meet objectives, subject to reductions In Pay for Performance, what must hospitals do in the capitation type initiative? - CORRECT ANSWER >>> for chronically ill, must guarantee CMS a savings of at least 5% over similar population
** room and board (by nursing unit, room type) and ancillary charges - will list UB-04 rev code, CPT/HCPCS code and charge amount What are level 1 CPT codes - CORRECT ANSWER >>> five numbers (for procedures) What are level 2 CPT codes - CORRECT ANSWER >>> for supplies, ambulance (alpha and 4 digits) What are level 3 CPT codes - CORRECT ANSWER >>> not common What are level 1 CPT modifiers - CORRECT ANSWER >>> eg would be 23 - unusual anesthesia What are level 11 CPT modifiers - CORRECT ANSWER >>> eg: LT - left side, E4 - lower right eyelid What are level III CPT modifiers - CORRECT ANSWER >>> XI - FDA approved drug Is there a chain to modifiers? - CORRECT ANSWER >>> Yes, a HCPCS level III has higher precedence than a HCPCS NP level II for example In Pay for Performance, what do hospitals do in the Hosp Qual Initiative? - CORRECT ANSWER >>> hosp must submit data about 10 quality measures In Pay for Performance, what must hospitals do in the Premier Hosp Quality initiative? - CORRECT ANSWER >>> If hosp score in top 10%, receive a 2% bonus, if not meet objectives, subject to reductions In Pay for Performance, what must hospitals do in the capitation type initiative? - CORRECT ANSWER >>> for chronically ill, must guarantee CMS a savings of at least 5% over similar population What is Pay for Performance? - CORRECT ANSWER >>> Pay-for-performance" is an umbrella term for initiatives aimed at improving the quality, efficiency, and overall value of health care. Pay-for-performance has become popular among policy makers and private and public payers, including Medicare and Medicaid. Formula for Net Days in Pt A/R - CORRECT ANSWER >>> Net Pt A/R
Net Revenue/365 (or time period) What does Net Days in Pt A/R tell us? - CORRECT ANSWER >>> indication of efficiency of collections, revenue posting, and financial ops of A/R Does Net Days in Pt A/R get aged from date of service, date bill sent, or? **- CORRECT ANSWER
** Date of service
What % of reserves are self pay bills 60-90 days from 1st bill - CORRECT ANSWER >>> 25% What % of reserves are medicare bills >365 days past discharge - CORRECT ANSWER >>> 20% What % of reserves are medicare bills 180-365 days past discharge - CORRECT ANSWER >>> 10% Are gross charges or contractural amounts posted to a pt's account? - CORRECT ANSWER >>> If know contractural amount can post, otherwise post gross charge to pt's account until insurance pays What are instances when - care is a 2ndry payer? - CORRECT ANSWER >>> Disability (pt <65, has LGHP), ESRD (in 30 day coordination period), working aged, accident (when no liability exists) What is the correct coding initiative? - CORRECT ANSWER >>> the purpose of the CCI is to ensure that the most comprehensive groups of codes are billed, rather than the component parts. developed by CMS What are some ways to avoid problems with cash postings? - CORRECT ANSWER >>> large write-offs such as bad debt should be done by managers. What does CMS require when there is a credit balance? - CORRECT ANSWER >>> reporting to CMS What does HFMA recommend a HCO do with a small credit to a pt payer? **- CORRECT ANSWER
** absorb if pt does not claim after a certain period of time
What is a bank lock box? - CORRECT ANSWER >>> contracting with a bank to receive, deposit, and electronically report payments from pts and payers What were the four goals of HIPAA passed in 1996? - CORRECT ANSWER >>> portability - the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs; Reduces health care fraud and abuse; Mandates industry-wide standards for health care information on electronic billing and other processes; and Requires the protection and confidential handling of protected health information What is APC? - CORRECT ANSWER >>> Ambulatory payment classification: United States government's method of paying for facility outpatient services for Medicare. analogous to the Medicare prospective payment system for hospital inpatients (DRG). APCs are an outpatient prospective payment system applicable only to hospitals. What is case rate? - CORRECT ANSWER >>> fixed price for specified procedure. Gives provider opportunity to manage costs before capitation. What is a silent PPO - CORRECT ANSWER >>> insurance companies that offer providers less payment, invalid discounts (they try to look like a contracted PPO) What is electronic remittance advice 835 data set? - CORRECT ANSWER >>> used to send hc claim payments and advice - four levels from receipt (then paper trail) to level 4 - all electronic and links bank. - Care uses level 4. Can a Medicare beneficiary request an appeal? - CORRECT ANSWER >>> yes, must be an amount >$130, judicial review if over $
What is exempt in bankruptcy? - CORRECT ANSWER >>> property (like house, personal items), alimony, tools of trade What is exempted from discharge in bankruptcy? - CORRECT ANSWER >>> education loans, gvt fines, unpaid alimony/child care, debts arisen from lying FAP (financial assistance program) and its charity agreements? **- CORRECT ANSWER
** nonprofits will have limitations on charges to uninsured how should a HCO determine poverty guidelines? - CORRECT ANSWER >>> Can use the federal poverty guidelines, income does not include capital gain, injury comp, sale of property - and is state defined What is catastrophic charity - CORRECT ANSWER >>> in the event of catastrophic injury or illness what is an open insurance balance? - CORRECT ANSWER >>> After 60 days, pt must pay or fight with insurance co. to pay (unless prohibitions in contract) what is subrogation? - CORRECT ANSWER >>> health plan bills liability insurance Will - Care pay for worker's comp - CORRECT ANSWER >>> No Will - Care pay for auto liability? - CORRECT ANSWER >>> Yes, after auto is exhausted What percent of claims and type are 80% of AR? - CORRECT ANSWER >>> 15 - 20% of high fee What's an example of a claim rejection for technical reasons? - CORRECT ANSWER
>>> demographic errors, no pre-authorization, exceeded frequency (only 1 PAP/yr) What's an example of a claim rejection for clinical reason? - CORRECT ANSWER >>> missing doc to support, HCPCS incorrect, not medically necessary What does a recovery audit contractor do? - CORRECT ANSWER >>> Review - Care claims to save gvt $ and prevent abuse What is unique about a rural health clinic and how it bills - Care part B **- CORRECT ANSWER
** Can collapse CPT codes to 520, but HFMA recommends still use CPT for medical necessity Are all - Care services in a RHC defined as rural health? - CORRECT ANSWER >>> No, such as SNF How are - Caid claims paid in a RHC? - CORRECT ANSWER >>> state by state rules Will - Care pay for a VA hospice? - CORRECT ANSWER >>> No, VA must pay Will - Care pay for hospice? - CORRECT ANSWER >>> Only if pt is entitled to - Care part A Can hospice be denied under - Care? - CORRECT ANSWER >>> yes, if worker's comp related or 210 days of hospice How is hospice payment worker compensation related? - CORRECT ANSWER >>> Could be cancer caused by exposure, worker's comp must cover, but - Care would then cover respite care, eg
How is medical necessity determined in ambulance? - CORRECT ANSWER >>> based on services provided, not type of ambulance used What is the FCA - CORRECT ANSWER >>> False Claims Act of 2009, fraud enforcement and recovery act, encourage whistleblowers When is - Care a MSP? - CORRECT ANSWER >>> group health plan, only if >20 employees, accident (some specifics on liability), disability (Unless >65), ESRD in 30 coordination period What is the 2 midnight rule - CORRECT ANSWER >>> 2 midnights or less can be outpt What is the CCI - CORRECT ANSWER >>> correct coding initiative - modifiers to help indicate a special circumstance (eg performed by > 1 MD) What are the 9 forms that should be on hand on admission - CORRECT ANSWER >>> consent to treatment condition of admission (financial agreement, surgical consent, release of info, assignment of benefits) privacy notice impt msg from - Care (can dispute) ADP Pt bill of rights How should a PFS introduce payment when speaking with a pt? - CORRECT ANSWER >>> 1. greet
- review HCO PFS policies
- review insurance
- review charges and liability
- how will pt resolve liability?
What are some problems if pt access not done correctly? - CORRECT ANSWER >>> 1. billing (lost revenue)
- clinical - in wrong file
- case review - where insurance must be notified w/in 24 hrs 4. legal What is the FDCA? - CORRECT ANSWER >>> Fair Debt Collection Act Hosp benchmark days A/R - CORRECT ANSWER >>> 40 - 45
