Download HFMA CRCR EXAM ACTUAL EXAM 350 QUESTIONS AND ANSWERS TESTBANK 2024-2025 and more Exams Nursing in PDF only on Docsity!
HFMA CRCR EXAM ACTUAL EXAM 350
QUESTIONS AND ANSWERS TESTBANK
VERSION 1
The rule by which CMS defines short-stay inpatient cases as generally eligible for reimbursement is the: - ANSWER✔✔Two Midnight Rule What restriction does a managed care plan place on locations that must be use if the plans is to pay for the services provided? - ANSWER✔✔Site of Service Limitation The Medicare Bundled Payments for Care Initiative (BCPI) is designed to: - ANSWER✔✔Align incentives between hospitals, physicians, and non-physician providers in order to better coordinate patient care For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions: - ANSWER✔✔Should take place between the patient or guarantor and properly trained provider representatives The soft cost of a dissatisfied customer is: - ANSWER✔✔The customer passing on information about their negative experience to potential patients or through social media channels What is likely to occur if credit balances are not identified separately from debit balances in accounts receivable? - ANSWER✔✔The accounts receivable level would be understated The best practice in billing is to generate bills and financial information that is - ANSWER✔✔Clear, concise, correct, and patient-friendly
What is Required for the UB-04/837-I, used by Rural Health Clinics to generate payment from Medicare? - ANSWER✔✔Revenue Codes What are some core elements of a board-approved financial policy? - ANSWER✔✔Charity care, payment methods, and installment payment guidelines 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: - ANSWER✔✔HMO Which level of HCPCS codes are assigned and maintained by Medicare Administrative Contractors? - ANSWER✔✔Level III The Two Midnight Rule allows hospitals to account for total Hospital time Including? - ANSWER✔✔Outpatient time directly preceding the inpatient admission Medicare patients are NOT required to produce a physician's order to receive which of these services? - ANSWER✔✔Screening of mammography, flu vaccine or pneumonia vaccine 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 - ANSWER✔✔Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow HIPAA has adopted Employer Identification Numbers (EINS) to be used in standard transactions to identify the employer of an individual described in a transaction. EINs are created and assigned by - ANSWER✔✔The Internal Revenue Service The revenue cycle includes - ANSWER✔✔All of the major processing steps required to process a patient account from the request for service through closing the account with a zero balance
APC used for - ANSWER✔✔Outpatient Billing EDI - ANSWER✔✔Electronic Data Interchange Benefit SNF Period? - ANSWER✔✔100 Days during a benefit period/ Benefit period ends during which the patient is not a IP or SNF for 60 days. Level 1 of ERA - ANSWER✔✔Receipt of Data/the information is printed 100 (often use of swing beds) - ANSWER✔✔Rural Hospitals with fewer than BLANK beds can be reimbursed by Medicare physicians, allied health professions, CRNA, home health agency's and Medical Equipment suppliers - ANSWER✔✔CMS 1500 is used by non-institutional providers such as Electronic remittance is received, entered into computer, and viewed at terminal - ANSWER✔✔Level 2 of ERA No Pre Auth, clinicals not called for certification, INS not verified, Inaccurate Data entry, Copying registration without verifying - ANSWER✔✔Pre Service Denials include Contractual allowance - ANSWER✔✔The difference between provider's charges and the insurance payment that are written off the patients account Electronic remittance is received, entered into computer - remittance data are electronically posted by the patient accounting software, updating the patients account. - ANSWER✔✔Level 3 of ERA
Examples of DME - ANSWER✔✔Wheelchairs, hospital beds, oxygen tanks Level 4 of ERA - ANSWER✔✔Total automation receipt, data entry, payment posting, adjustment processing Truth and Lending Act is... - ANSWER✔✔Total automation receipt, data entry, payment posting, adjustment processing Remittance - ANSWER✔✔ 835 Which provision protects the patient from Medical expenses that exceed a pre-set level? - ANSWER✔✔Capitation Which type of issues will cause Medicare to reject a claim? - ANSWER✔✔MSP If a patient remains an inpatient of an SNF for more than 30 days, what is the SNF permitted to do? - ANSWER✔✔Submit interim bills to the Medicare program The rule by which CMS defines short-stay inpatient cases as generally eligible for reimbursement is the: - ANSWER✔✔Two Midnight Rule What restriction does a managed care plan on locations that must be used if the plan is to pay for the services provided? - ANSWER✔✔Site of Service Limitation Which of the following statements is true about third-party payments? - ANSWER✔✔The payments represent only liability claim payments
What is the intended outcome of collaborations made through an ACO delivery system? - ANSWER✔✔To ensure appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients. Why was ACA designed for? - ANSWER✔✔The Affordable Care Act was designed to reform the healthcare system into a system that rewards greater value, improved the quality of care and increase efficiency in the delivery of services. Which option is not a reserve amount on a provider's financial statement? - ANSWER✔✔Contra Account Amounts What are KPIs? - ANSWER✔✔Key performance indicators, which set standards for accounts receivable (A/R) and provide a method of measuring the collection and control of A/R. Which patients are considered scheduled? - ANSWER✔✔Recurring / Series Patients Name the guideline that Medicare established to determine which diagnoses, signs, or symptoms are payable. - ANSWER✔✔Local Coverage Determination (LCD) What is the purpose of insurance verification? - ANSWER✔✔To ensure accuracy of the health plan information. Which option is a federally-aided, state-operated program to provide health and long-term care coverage? - ANSWER✔✔Medicaid Which option is not a specific managed care requirement? - ANSWER✔✔Preferred Provider Organization HMO Plan - ANSWER✔✔Provides comprehensive healthcare services, within a designated population on a pre payment basis
PPO - ANSWER✔✔Group of medical providers is identified to furnish services at lower than usual fees POS - ANSWER✔✔Members can refer themselves outside the plan and still get some coverage CDHP - ANSWER✔✔Subscriber agrees to a high initial deductible, in return for lower premiums What is the first component of a pricing determination? - ANSWER✔✔Verification of the patients insurance elig and benefits. What is the purpose of financial counseling? - ANSWER✔✔To educate the patient on his/her health plan coverage and financial responsibility for healthcare services What does EMTALA require hospitals to do? - ANSWER✔✔To provide a medical screening examination and stabilizing treatment to every person presenting at an ED and requesting medical evaluation or treatment. In what manner do case managers assist revenue cycle staff? - ANSWER✔✔Providing assistance with written appeals to health plans related to utilization and other care issues. Level I HCPCS Modifier - ANSWER✔✔Approved American Medical Associations CPT 4 Codes Level II HCPCS Modifier - ANSWER✔✔CMS Developed codes for classifying supplies and non physician services Level III HCPCS Modifier - ANSWER✔✔Codes assigned and maintained by Medicare Administrative Contractors
What is subrogation? - ANSWER✔✔The follow up on activities for liability payers, i.e. workers comp, auto medical ins coverage, premises medical coverage for property cases. Upon being billed , the health plan may process the claim for reimbursement and subsequently pursue payment from the liability payer. Which option does not have to be considered when initiating self-pay follow up and account resolution activities? - ANSWER✔✔Patient Open Balance Billing Which option is not a bankruptcy type? - ANSWER✔✔Creditor Priority Through what document does a hospital establish compliance standards? - ANSWER✔✔Code of Conduct What is the purpose of the OIG work plan? - ANSWER✔✔Communicate Issues that will be reviewed during the year for compliance with Medicare Regulations If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - ANSWER✔✔Diagnostic services and related charges provided on Wednesday, Thursday and Friday before admission. What does a modifier allow a provider to do? - ANSWER✔✔Report a specific circumstance that affected a procedure or service without changing the code or its definition If outpatient diagnostic services are provided within three days of the admission of a Medicare beneficiary to an IPPS (Inpatient Prospective Payment System) hospital, what must happen to these charges? - ANSWER✔✔They must be combined with the inpatient bill and paid under the MS-DRG (diagnosis related group) system. 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? - ANSWER✔✔It reviews Medicare payments for beneficiaries who have other insurance and assesses the effectiveness of procedures in preventing inappropriate Medicare payments for beneficiaries with other insurance coverage. What is a recurring or series registration? - ANSWER✔✔One registration record is created for multiple days of service. What are nonemergency patients who come for service without prior notification to the provider called? - ANSWER✔✔Unscheduled Patients Which of the following statements apply to the observation patient type? - ANSWER✔✔It is used to evaluate the need for an inpatient admission. Which services are hospice programs required to provide on an around-the-clock basis? - ANSWER✔✔Physician, nursing and pharmacy What is the purpose of the initial step in the outpatient testing scheduling process? - ANSWER✔✔Identify the correct patient on the providers database or add the patient to the database Scheduler instructions are used to prompt the scheduler to do what? - ANSWER✔✔Complete the scheduling process correctly based on service requested. The time needed to prepare the patient before service is the difference between the patient's arrival time and which of the following? - ANSWER✔✔Procedure time Medicare guidelines require that when a test is ordered for which as LCD (local coverage determination) or NCD (national coverage determination) exist, the information provided on the order must include which of the following? - ANSWER✔✔Documentation of the medical necessity of the test.
What document must a primary care physician send to an HMO (health maintenance organization) patient to authorize a visit to a specialist for additional testing or care? - ANSWER✔✔Referral What activities are completed when a scheduled, pre-registered patient arrives for service? - ANSWER✔✔Activating the record, obtaining signatures, and finalizing financial issues. 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 - ANSWER✔✔Medical Screening and Stabilizing Treatment Collecting patient liability dollars after service leads to what? - ANSWER✔✔Increased efforts by patient accounting staff to resolve these balances. The important Message from Medicare (IM) provides beneficiaries with information concerning what? - ANSWER✔✔Right to appeal discharge decision if the patient disagrees with the plan. What circumstances would result in an incorrect nightly room charge? - ANSWER✔✔If the patient's transfer from the ICU (intensive care unit) to the medical/surgical floor is not reflected in the registration system Which of the following is a step in the discharge process? - ANSWER✔✔Have case management services complete the discharge plan Which of the following statements describes the goal of financial counseling services? - ANSWER✔✔To help the patient understand insurance coverage, including what the patient will owe for the current services The hospital has an APC (ambulatory payment classification)-based contract for the payment of outpatient services. Total anticipated charges for the visit are $2.380. The approved APC payment rate is $780. Where will the patient's benefit package be applied? - ANSWER✔✔To the approved APC payment rate
A patient has met the $200 individual deductible and $900 of the $1000 coinsurance responsibility. The coinsurance rate is 20%. The estimated insurance plan responsibility is $1,975. What amount of coinsurance is due from the patient? - ANSWER✔✔$ Which of the following items are considered valid proof of income documents? - ANSWER✔✔Copies of paycheck stubs from the most recent three months When is a patient considered to be medically indigent - ANSWER✔✔The patient's outstanding medical bills exceed a defined dollar amount or percentage of assets What patient assets are considered in the financial assistance application? - ANSWER✔✔Sources of readily available finds, such as vehicles, campers, boats, and savings accounts If patient cannot agree to payment arrangements, what is the next option? - ANSWER✔✔Initiate Medicaid eligibility and financial assistance screenings What are numbered receipts used for? - ANSWER✔✔To ensure that all payments are properly accounted for and deposited What is an effective tool to help staff collect payments at time of service? - ANSWER✔✔Develop scripts for the process of requesting payments At the end of each shift, what must happen to cash, checks, and credit card transaction documents? - ANSWER✔✔They must be balanced Why is it importance to have high quality standards for registration? - ANSWER✔✔Because quality failures may have legal implications.
Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - ANSWER✔✔Healthcare Costs In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - ANSWER✔✔Packaged Pricing What restriction does a managed care plan place on locations that must be used if the plan is to pay for the services provided? - ANSWER✔✔Site of service limitation Which of the following statements applies to private rooms? - ANSWER✔✔If the medical necessity for a private room is documented in the chart, the patient's insurance will be billed for the differential. Which of the following is true about attempting to collect patient liability amounts after service? - ANSWER✔✔It is inefficient and results in higher bad-debts levels Which of the following is true about screening a beneficiary for possible MSP (Medicare Secondary Payer) situations? - ANSWER✔✔It is necessary to ask the patient each of the MSP questions What do the MSP (Medicare Secondary Payer) disability rules require? - ANSWER✔✔That the patient is younger than 65 years Which of the following techniques is an acceptable way to complete the MSP (Medicare Secondary Payer) screening for a liability situation? - ANSWER✔✔Ask if the current service is related to an accident Which of the following is a valid reason for a payer to deny a claim? - ANSWER✔✔Failure to complete authorization requirements
Which of the following statements is not a possible consequence of selecting the wrong patient in the MPI (Master patient index)? - ANSWER✔✔Claim is paid in full Comprehensive pre-registration data includes which of the following? - ANSWER✔✔Complete insurance and emergency contact information Which of the following statements is true of a Medicare Advantage Plan? - ANSWER✔✔This is a managed care plan for Medicare beneficiaries Which of the following is not a characteristics of a Medicaid HMO (health maintenance organization) plan? - ANSWER✔✔Medicaid-eligible patients are never required to join a Medicaid HMO plan Which of the following statements describes the APC (ambulatory payment classification) system? - ANSWER✔✔APC rates are calculated on a national basis and are wage-adjusted by geographic region What process does a managed care plan use to determine if health care services are appropriate for a patient's condition? - ANSWER✔✔Authorize services before they are provided and strictly limit days of inpatient care approved without additional clinical information from the provider Which of the following is a violation of the EMTALA (Emergency Medical Treatment and Labor Act)? - ANSWER✔✔Registration staff members routinely contact managed care plans for prior authorizations before the patient is seen by the on-duty physician Which of the following statements is true of the Important Message from Medicare notification requirements? - ANSWER✔✔Notification is only required if the patients discharge decision is in dispute
How are charges recorded as charity care treated? - ANSWER✔✔As a deduction from revenue that is treated as an expense in the financial statements What three types of utilization review are used to ensure that resources and services are provided in the most efficient and effective ways? - ANSWER✔✔Prospective review, concurrent review, and retrospective review The situation where neither the patient nor spouse is employed is described - ANSWER✔✔A Condition Code The regulations and requirement for creating accountable care organizations, which allowed providers to begin creating these organizations, were finalized in - ANSWER✔✔ 2010 What is the correct discharge status code for a patient who is discharged to a swing bed unit in the same hospital? - ANSWER✔✔ 61 What is a primary responsibility of the Recovery Audit Contractor? - ANSWER✔✔To correctly identify proper payments for Medicare Part A & B claims The 501 r regulations require not-for-profit providers (501 (c) 3) to do which of the following activities. - ANSWER✔✔Implement a financial assistance program for uninsured and underinsured patients What type of plan restricts benefits for nonemergency care to approved providers? - ANSWER✔✔An EPO (exclusive provider organization) plan What is IPPS - ANSWER✔✔inpatient prospective payment system
What is CCI - ANSWER✔✔The Correct Coding Initiative. It is used to promote proper coding for reimbursement of health care. CCI effects PT by not allowing two CPT codes to be billed together What does scheduling allow provider staff to do? - ANSWER✔✔Review the appropriateness of the service request When an adult patient is covered by both his own and his spouse's health insurance plan, which of the following statements is correct? - ANSWER✔✔The patient's insurance plan is primary LCD - ANSWER✔✔Local Coverage Determination NCD - ANSWER✔✔National Coverage Determination If a claim is related to an accident, what must the hospital report? - ANSWER✔✔State where the incident occurred. Mrs. Jones, a Medicare beneficiary, was admitted to the hospital on June 20, 2010. As of the admission date, she had only used 8 inpatient days in the current benefit period. If she is not discharged, on what date will Mrs. Jones exhaust her full coverage days? - ANSWER✔✔Aug 9, 2010 In order to meet eligibility guidelines for healthcare benefits, Medicaid beneficiaries must fall into a specified need category and meet what other types of requirements? - ANSWER✔✔Income and Asset Most managed care plans do not permit patient balance billing except for what circumstance? - ANSWER✔✔Deductible and copay requirements.
