Download Analyzing Denials and Improving Billing Compliance in Healthcare and more Exams Health sciences in PDF only on Docsity!
CRCR Certification Exam Questions and Answers , (Verified
Answers by Expert) (A+).
The 501(r) regulations require not-for-profit providers 501(c) (3) to do which of the following activities? A. Complete a community needs assessment and develop a discount program for patient balances after insurance payment. B. Pursue extraordinary collection activities with all patients eligible for financial assistance. C. Implement a financial assistance program for uninsured and underinsured patients. D. Discount all charges to self-pay patients to an amount generally billed to all other patients. -
answers A. Complete a community needs assessment and develop a discount program for
patient balances after insurance payment The accurate capture of charges remains critically important because: A. Of the potential of fraud and abuse charges from erroneous billing. B. Charges remain one of the few consistent indicators available to monitor resource use. C. Charges are means of measuring physician productivity.
D. Charges provide the data used in activity based costing. - answers B. Charges remain one
of the few consistent indicators available to monitor resource use The ACO investment model will test the use of pre-paid shared savings to: A. Invest in treatment protocols that reduce costs to Medicare B. Attract physicians to participate in the ACO payment system.
C. Raise quality ratings in designated hospitals.
D. Encourage new ACOs to form in rural and underserved areas. - answers D. Encourage new
ACOs to form in rural and underserved areas 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. Have a patient financial responsibilities kit ready for the patient, containing all of the required registration forms and instructions. B. Make sure that the attending staff can answer questions and assist in obtaining required patient financial data. 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. -
answers C. Support that choice, providing that the discussion does not interfere with patient
care or disrupt patient flow Activities completed when the scheduled, pre-registered patient arrives for service includes: A. Verifying insurance, activating the record and directing the patient to the service area. B. Scanning the driver's license or other phot identification and directing the patient to the financial counselor. C. Activating the record, obtaining signatures and finalizing financial issues.
D. Registering the patient and directing the patient to the service area. - answers C.
Activating the record, obtaining signatures and
D. Meet federal mandates for insurance coverage and obtain the corresponding tax deduction -
answers C. Purchase qualified health benefit plans regardless of insured's health status.
All of the following are conditions that disqualify a procedure or service from being paid for by Medicare EXCEPT: A. Offered in an outpatient setting B. Medically unnecessary C. Not delivered in a Medicare licensed care setting.
D. Services and procedures that are custodial in nature - answers C. Not delivered in a
Medicare licensed care setting All of the following are reference resources used to help guide in the application for business ethics EXCEPT: A. Consumer satisfaction reports B. Mission & Value Statements C. Code of Ethics / Code of Conduct
D. Compliance Office & Policies - answers A. Consumer satisfaction reports
All of the following are steps in safeguarding collections EXCEPT: A. Placing collections in a lock-box for posting review the next business day. B. Posting the payment to the patient's account C. Completing balancing activities
D. Issuing receipts - answers A. Placing collections in a lock-box for posting review the next
business day All of the following are steps in verifying insurance EXCEPT: A. Sequencing plans involved in a coordination of benefits (COB) situation. B. The patient signing the statement of financial responsibility. C. Identifying and documenting the patient's health plan benefits
D. Confirming the patient's eligibility for benefits - answers B. The patient signing the
statement of financial responsibility All of the following information is used to identify a patient EXCEPT: A. Date of Birth B. Gender C. Social Security Number
D. Address - answers D. Address
All of the following information should be reviewed as part of schedule finalization EXCEPT: A. The estimated patient financial obligations B. The service to be provided C. The arrival time and procedure time
D. The patient's preparation instructions - answers A. The estimated patient financial
obligations
D. The Office of the Inspector General - answers A. The Provider Reimbursement Review
Board Applying the contracted payment methodology to the total charges yields: A. An estimated price B. An anticipated health plan payment C. A price justified revenue accrual
D. A pricing agreement - answers A. An estimated price
Appropriate training for the patient financial counselling 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 record
D. Available patient financing options - answers C. Documenting the conversation in the
medical record The basis for qualification in Medicaid is typically: A. The Federal Poverty Guidelines B. Financial need as demonstrated by the prior two-years federal income tax fillings C. The patient's score on the Internal Revenue Service's Personal Wealth and Spending indicator
D. Bank statements for the previous 18 months - answers A. The Federal Poverty Guidelines
Because 501(r) regulations focus on identifying potentially eligible financial assistance patients, hospitals must: A. Capture their experience with such patients to properly budget B. Hold financial conversations with patients as soon as possible C. Build the necessary processes to handle the potentially lengthy payment schedules D. Expedite payment processing of normal accounts receivables to protect cash flow -
answers B. Hold financial conversations with patients as soon as possible
Before classifying and subsequently writing off an account to financial assistance or bad debt, the hospital must establish policy, define appropriate criteria, implementation, identifying and processing accounts and: A. Obtain the patients income tax statements from the prior 2 years B. Having the account triaged for any partial payment possibilities C. Monitor compliance
D. Assist in arranging for a commercial bank loan - answers C. Monitor compliance
The benefit of a Medicare Advantage Plan is: A. It is a less costly plan compared to traditional Medicare B. Patients may retain a primary care physician and see another physician for a second opinion at no charge C. Patients generally have their entire Medicare-covered healthcare through the plan and do not need to worry about "Part A" or "Part B' benefits
C. To specific cases designated by third-party contractual agreement
D. To patients of any physician requesting case management - answers B. To every patient
Claims edits are: A. Rules developed to verify the accuracy of claims based on each health plan's policies B. The specific reimbursement areas of a claim that are denied by the health plan C. Special addendums to the claim allowing the provider to submit additional documentation D. Triggers in the health plan claim adjudication system that disallows reimbursement -
answers A. Rules developed to verify the accuracy of claims based on each health plan's
policies Claims with dates of service received later than one year beyond the date of service, will be: A. Denied by Medicare B. The full responsibility of the patient C. The provider's responsibility but can be deemed charity care
D. Fully paid with interest - answers A. Denied by Medicare
A "Compliance Program" is defined as: A. Educating staff on regulations B. The development of operational policies that correspond to regulations C. Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met
D. Annual legal audit and review for adherence to regulations - answers C. Systematic
procedures to ensure that provisions of regulations imposed by government agency are being met The concept encompasses all activities required to send a request for payment to a third-party health plan for payment of benefits: A. Billing B. Account resolution C. Claims Processing
D. Third-party invoicing - answers C. Claims processing
Concurrent review and discharge planning: A. Occurs during service B. Is performed by the health plan during the time of service C. Is a significant part of quality and is performed by the clinical treatment team
D. Is performed at discharge with the patient - answers C. Is a significant part of quality and is
preformed by the clinical treatment team A decision of whether a patient should be admitted as an inpatient or become an outpatient observation patient requires medical judgments based on all of the following EXCEPT: A. The patient's medical history B. The safe-guarding against medical error
C. The patient must give consent
D. A transfer request must be made to staff responsible for bed assignments - answers D. A
transfer request must be made to staff responsible for bed assignments The enhanced data-mining opportunities that results from the more detailed coding under ICD- 10 allow senior leadership to work with physicians to do all of the following EXCEPT: A. Improve outcomes B. Obtain higher compensation for physicians C. Embrace new reimbursement models
D. Drive significant improvements in areas of quality and the patient experience - answers B.
Obtain higher compensation for physicians Failure to take the appropriate precautions with a bankruptcy account, to identify and isolate the debtor's accounts from further collection activity: A. Provides evidence of unauthorized extraordinary collections activity B. Could be in violation of a court's order C. May violate the provisions of the patient protection regulations
D. Could potentially create under "write-offs" - answers B. Could be in violation of a court's
order The first thing a health plan does when processing a claim is: A. Review to make sure the claim is complete
B. Verify if the provider(s) is(are) in network or not C. Check if the patient is covered
D. Confirm if deductibles and con-insurance requirements have been met - answers C. Check
if the patient is covered For Medicare patients, an important component of the pre-registration process is: A. Obtaining clear physician's orders B. Verifying Medicare eligibility C. Clear authorization for all services covered in Part A D. The effective completion of the Medicare Secondary Payer (MSP) screening process -
answers D. The effective completion of the Medicare Secondary Payer (MSP) screening
process For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions: A. May take place between the patient and discharge planning B. Should take place between the patient or guarantor and properly trained provider representatives C. Are optional
D. Are focused on verifying required third-party information - answers B. Should take place
between the patient or guarantor and properly trained provider representatives
D. to review all claims processing for compliance with contractual agreements - answers B. To
analyze the type and sources of denials and consider process changes to eliminate further denials The healthcare industry is vulnerable to compliance issues, in large part due to the complexity of the statues and regulations pertaining to: A. Patient financial obligations for the entire cost of treatment B. Unregulated market activity for third-party payers C. Medicare and Medicaid payments
D. Commercial third-party payers - answers C. Medicare and Medicaid payments
Health Information Management (HIM) is responsible for: A. All patient medical records B. The maintenance of all software applications C. The maintenance of the entire technology infrastructure
D. Clean claims being filed - answers A. All patient medical records
Health Plan Contracting Departments do all the following EXCEPT: A. Reimbursement rate setting B. Review all managed care contracts for accuracy and load contract terms into the patient accounting system
C. Review payment schemes to ensure that the health plan and provider understand how reimbursements must be calculated D. Review contracts to ensure the appeals process for denied claims is clearly specified -
answers A. Reimbursement rate setting
HFMA best practices call for patient financial discussions to be reinforced: A. By obtaining some type of collateral B. With a written statement of the conversation C. By issuing a new invoice to the patient
D. Ny copying the provider's attorney on a written statement of the conversation - answers B.
With a written statement of the conversation HFMA best practice specify that, In an Emergency Department setting: A. Financial conversations are inappropriate B. Financial conversations be brief and focused on obtaining third-party payer information C. Financial conversations be focused on obtaining basic demographic data needed to create the patient account D. No patient financial discussions should occur before a patient is screened and stabilized -
answers D. No patient financial discussions should occur before a patient is screened and
stabilized HFMA best practices stipulate that a reasonable attempt should be made to have the financial responsibilities discussion:
HIPAA has adopted Employer Identification Numbers (EINs) to be used in standard transactions to identify the employer of an individual described transaction. EINs are created and assigned by: A. The Social Security Administration B. The United States Department of the Treasury C. The United States Department of Labor
D. The Internal Revenue Service - answers D. The Internal Revenue Service
HIPAA privacy rules require covered entitles to take all of the following actions EXCEPT: A. Develop written policies and procedures including a description of staff who have access to protected information B. Define protected health information and access thereto by individuals, health plans, and business associates C. Ensure that a privacy officer is hired/designated
D. Use only designated software platforms to secure patient data - answers D. Use only
designated software platforms to secure patient data Hospitals can only convert an inpatient case to observation if the hospital utilization review committee determines this status before the patient is discharged and: A. With the consent of the third-party payer's medical director that and observation setting will be more appropriate B. After any billing C. Before closing the patient's account
D. Prior to billing, that an observation setting will be more appropriate - answers D. Prior to
billing, that an observation setting will be more appropriate Hospitals can only convert to an inpatient case to observation if: A. The patient's health plan approves B. The hospital utilization review committee determines before the patient is discharged and prior to billing, that an observation setting would be more appropriate C. The level of intensity of treatment does not warrant an admission D. The patient in consultation with the attending and before billing requests the change -
answers B. The hospital utilization review determines before the patient is discharged and
prior to billing, that an observation setting would be more appropriate Hospitals need which of the following information sets to assess a patient's financial status? A. Income, Expenses, Debt B. Demographic, Income, Assets, Expenses C. Income, Expenses, and Capacity to take on more debt
D. Asset liquidity, Income, Expenses, Credit worthiness - answers B. Demographic, Income,
Assets, Expenses ICD-10-CM and ICD-10-PCD code sets are modifications of: A. The international ICD-10 codes as developed by the WHO (World Health Organization) B. ICD 9 codes
