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CRCR FINAL EXAM QUESTIONS & ANSWERS ALREADY A+
GRADED
What are collection agency fees based on? - CORRECT ANSWER >>> A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - CORRECT ANSWER >>> Birthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - CORRECT ANSWER >>> Case rates What customer service improvements might improve the patient accounts department? - CORRECT ANSWER >>> Holding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - CORRECT ANSWER >>> Inform 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? - CORRECT ANSWER >>> Bad debt adjustment What is the initial hospice benefit? - CORRECT ANSWER >>> Two 90-day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - CORRECT 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? - CORRECT ANSWER >>> Post a late-charge adjustment to the account an increase in the dollars aged greater than 90 days from date of service indicate what about accounts - CORRECT ANSWER >>> They are not being processed in a timely manner What is an advantage of a preregistration program? - CORRECT ANSWER >>> It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? **- CORRECT ANSWER
** Medically unnecessary services and custodial care What core financial activities are resolved within patient access? **- CORRECT ANSWER ** Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts What statement applies to the scheduled outpatient? - CORRECT ANSWER >>> The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - CORRECT ANSWER >>> Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount What type of patient status is used to evaluate the patient's need for inpatient care? - CORRECT ANSWER >>> Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - CORRECT ANSWER >>> Medically necessary inpatient hospital services for at least 3 consecutive days before the skilled nursing care admission
What are hospitals required to do for Medicare credit balance accounts? **- CORRECT 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? - CORRECT 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: - CORRECT ANSWER >>> A valid CPT or HCPCS code With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what? - CORRECT ANSWER >>> Access their information and perform functions on-line What date is required on all CMS 1500 claim forms? - CORRECT ANSWER >>> onset date of current illness What does scheduling allow provider staff to do - CORRECT ANSWER >>> Review appropriateness of the service request What code is used to report the provider's most common semiprivate room rate? - CORRECT ANSWER >>> Condition code Regulations and requirements for coding accountable care organizations, which allows providers to begin creating these organizations, were finalized in: - CORRECT ANSWER >>> 2012 What is a primary responsibility of the Recover Audit Contractor? - CORRECT ANSWER >>> To correctly identify proper payments for Medicare Part A & B claims
How must providers handle credit balances? - CORRECT ANSWER >>> Comply with state statutes concerning reporting credit balance Insurance verification results in what? - CORRECT ANSWER >>> The accurate identification of the patient's eligibility and benefits What form is used to bill Medicare for rural health clinics? - CORRECT ANSWER >>> CMS 1500 What activities are completed when a scheduled pre-registered patient arrives for service? - CORRECT ANSWER >>> Registering the patient and directing the patient to the service area In addition to being supported by information found in the patient's chart, a CMS 1500 claim must be coded using what? - CORRECT ANSWER >>> HCPCS (Healthcare Common Procedure Coding system) What results from a denied claim? - CORRECT ANSWER >>> The provider incurs rework and appeal costs Why does the financial counselor need pricing for services? - CORRECT ANSWER >>> To calculate the patient's financial responsibility What type of provider bills third-party payers using CMS 1500 form **- CORRECT ANSWER
** Hospital-based mammography centers How are disputes with nongovernmental payers resolved? - CORRECT ANSWER >>> Appeal conditions specified in the individual payer's contract
What will cause a CMS 1500 claim to be rejected? - CORRECT 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? - CORRECT ANSWER >>> The cost of the test how are HCPCS codes and the appropriate modifiers used? - CORRECT 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? - CORRECT 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? - CORRECT ANSWER >>> Patient arrival processing is expedited, reducing wait times and delays What is a characteristic of a managed contracting methodology? **- CORRECT ANSWER
** Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - CORRECT 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? **- CORRECT
ANSWER >>>** Blue Cross and blue Shield What is true about screening a beneficiary for possible MSP situations? **- CORRECT 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? - CORRECT 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? - CORRECT ANSWER >>> Receive a fixed for specific procedures What will comprehensive patient access processing accomplish? **- CORRECT ANSWER
** Minimize the need for follow-up on insurance accounts Through what document does a hospital establish compliance standards? **- CORRECT ANSWER ** Code of conduct How does utilization review staff use correct insurance information? - CORRECT ANSWER >>> To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - CORRECT ANSWER >>> As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? **- CORRECT 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? - CORRECT ANSWER >>> Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - CORRECT ANSWER >>> Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail
Every patient who is new to the healthcare provider must be offered what? **- CORRECT ANSWER
** A printed copy of the provider's privacy notice How may a collection agency demonstrate its performance? - CORRECT 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? - CORRECT 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? - CORRECT ANSWER >>> The UB-04 and the CMS 1500 Unless the patient encounter is an emergency, what is the efficient and effective procedure for ** As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI? - CORRECT 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? - CORRECT ANSWER >>> Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - CORRECT ANSWER >>> Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail Every patient who is new to the healthcare provider must be offered what? - CORRECT ANSWER >>> A printed copy of the provider's privacy notice How may a collection agency demonstrate its performance? - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT ANSWER >>> Obtain the required demographic and insurance information before services are rendered what protocol was developed through the Patient Friendly Billing Project? **- CORRECT 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? - CORRECT ANSWER >>> Ask if the patient's current services was accident related What is a valid reason for a payer to delay a claim? - CORRECT 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) hospital, what must happen to
these charges - CORRECT ANSWER >>> They must be combined with the inpatient bill and paid under the MS-DRG system What do large adjustments require? - CORRECT ANSWER >>> Manager-level approval What items are valid identifiers to establish a patient's identification? **- CORRECT ANSWER
** Photo identification, date of birth, and social security number What must a provider do to qualify an account as a Medicare bad debts? **- CORRECT ANSWER ** Pursue the account for 120 days and then refer it to an outside collection agency What restriction does a managed care plan place on locations that must be used if the plan is to pay for the services provided? - CORRECT ANSWER >>> Site-of-service limitation What is an example of an outcome of the Patient Friendly Billing Project? - CORRECT ANSWER >>> Redesigned patient billing statements using patient-friendly language What statement describes the APC (Ambulatory payment classification) system? - CORRECT ANSWER >>> APC rates are calculated on a national basis and are wage-adjusted by geographic region What is a benefit of insurance verification? - CORRECT ANSWER >>> Pre-certification or preauthorization requirements are confirmed What is an effective tool to help staff collect payments at the time of service? - CORRECT ANSWER >>> Develop scripts for the process of requesting payments
Coordination of benefits (COB) - CORRECT 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 - CORRECT 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 - CORRECT ANSWER >>> Patient status regarding coverage for healthcare insurance benefits First dollar coverage - CORRECT ANSWER >>> A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses Gatekeeping - CORRECT 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 - CORRECT ANSWER >>> an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - CORRECT ANSWER >>> negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary - CORRECT 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 - CORRECT ANSWER >>> healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out-of-pocket payments - CORRECT ANSWER >>> Cash payments made by the insured for services not covered by the health insurance plan Pre-admission review - CORRECT 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 - CORRECT ANSWER >>> A restriction on payments for charges directly resulting from a pre-existing health conditions Same-day admission - CORRECT 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 - CORRECT ANSWER >>> Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Subrogation - CORRECT ANSWER >>> Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses Subscriber - CORRECT 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 - CORRECT ANSWER >>> A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery
Provider - CORRECT ANSWER >>> An entity, organization, or individual that furnishes a healthcare service Out of pocket payment - CORRECT 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 - CORRECT 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 - CORRECT 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? - CORRECT ANSWER >>> Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations FERA - CORRECT ANSWER >>> Fraud Enforcement and Recovery act ESRD - CORRECT 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? - CORRECT ANSWER >>> Mitigate potential fraud and abuse in the industry-specific key risk areas What is important about an effective corporate compliance program? - CORRECT 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 - CORRECT 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? - CORRECT 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. - CORRECT ANSWER >>> TRUE The OIG has issued compliance guidance/model compliance plans for all of the following entities: - CORRECT ANSWER >>> hospices. physician practices. ambulance providers Providers who are found to be in violation of CMS regulations are subject to: - CORRECT ANSWER >>> Corporate integrity agreements What MSP situation requires LGHP - CORRECT ANSWER >>> Disability
