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Comprehensive Test- Principals of
Healthcare Reimbursement and Revenue
Cycle Management Review Questions and
Answers 2024/
The US healthcare sector represents a significant portion of the US economy. The trend of _________ spending on healthcare has been consistent for more than a decade. increased The goal of revenue integrity is to produce a claim that is __________. Clean, complete, and compliant A physician office submitting an invoice (claim) for payment when the patient has health insurance is an example of a transaction between ________ and ________. Provider; third-party payer In the US, what is health insurance? Reduction of a person's or a group's exposure to risk for unknown healthcare costs by the assumption of that risk by an entity An employee paying for 40 percent of the insurance premium through payroll processing is an example of a transaction between ________ and ________. Patient; employer Which of the following is not a principle of revenue integrity? No oversight In this healthcare delivery model, the insurance company determines that contribution amount that is not based on the policyholder's income: Private health insurance model Successful RCM programs use this type of approach, which promotes collaboration amount various clinical departments and emphasizes and education strategy for all members: Multidisciplinary model
In this healthcare delivery model, employees and employers contribute an income-based amount of money to funds that are regulated by the government: Social insurance model Which of the following is a key factor in establishing a highly ethical culture that promotes honesty and openness? Transparency Which of the following types of care represent healthcare services not delivered by MCOs? Experimental devices What is the term that means evaluating, for a healthcare service, the appropriateness of its setting and its level of service? Utilization review In the healthcare sector, what is the term for a group of individual entities, such as individual persons, employers, or associations, whose healthcare costs are combined for evaluating financial history and estimating future costs? Risk pool All of the following activities are steps in medical necessity and utilization review except: Administrative review All of the following functions are ways that MCOs work toward their goal of controlling cost except: Use of evidence based clinical practice guidelines Medicare has four criteria to define medically necessary services. Which of the following is not one of the four criteria? Considered to be good medical practice by the physician providing the service Once the maximum out-of-pocket benefit is activated, all covered healthcare services for that policyholder or beneficiary are paid at 100 percent by the health insurance plan. The policyholder is not liable for _________ beyond the maximum out-of-pocket amount. Cost sharing amounts Managed care plans control beneficiary choice of provider. On the continuum of control, which type of managed care organization has the most control and, therefore, has the greatest limitations on a beneficiary seeing a provider that is not in-network? Health maintenance organization
Giant ACO has agreed to a shared savings rate of 65 percent and a shared loss rate of 40 percent with CMS. Giant ACO participates in a __________ risk agreement. Two-sided CMS uses this reimbursement methodology when they contract with Medicare Advantage Payers to care for Medicare beneficiaries under Medicare Part C. Capitation The pathologist's office submitted a $54 bill for a laboratory test. In its payment notice (remittance advice), the healthcare plan lists its payment for the laboratory test as $28. What does the amount of $54 represent? Billed charges Dr. Jones is a podiatrist who performs over 100 bunionectomies a year. Several of Dr. Jones' patients are insured by Super Payer. Super Payer reimburses Dr. Jones one amount for the preoperative visit, the surgery, and routine post-operative follow-up visits. Which reimbursement methodology does Super Payer use to reimburse Dr. Jones? Global payment method Dr. McGee is a primary care physician. Several of Dr. McGee's patients are insured by Super Payer. Super Payer reimburses Dr. McGee for each service she provides during a clinic visit. Which reimbursement methodology does Super Payer use to reimburse Dr. McGee? Fee schedule CMS uses which reimbursement methodology for inpatient psychiatric facility services payment system because a specific payment rate is established for each day of the admission? Per diem Dr. Ward is an endocrinologist who is part of the City Endocrinologist Specialists practice. Super Payer reimburses City Endocrinologist Specialists $450 per month for each of the 250 beneficiaries assigned to their care. Which type of reimbursement methodology is Super Payer using to reimburse City Endocrinologist Specialists? Capitation The CMS-HCC model uses ___________ and __________ to predict the patient's healthcare costs. Patient demographic characteristics; health status
Mr. Brown was admitted to the hospital with severe chest pains. During his encounter, he underwent a coronary artery bypass procedure (CABG) due to coronary artery disease (CAD). What is the first step in determining the MS-DRG assignment for this encounter? Determine if the coronary artery bypass procedure is one of the pre-MDC procedures The post-acute care transfer policy treats __________________. Type 2 transfers like type 1 transfers for certain MS-DRGs In MS-DRGs, the case-mix index is a proxy for what? Consumption of resources Fatima is calculating the MS-DRG for an inpatient admission. She has determined that the encounter does not qualify for pre-MDC assignment. What is the next step in the MS- DRG assignment process? Determine the MDC for the principal diagnosis. The MS-DRG payment includes reimbursement for all of the following inpatient services except: Physician hospital visit Which of the following statements about the IPPS high-cost outlier provision is false? The outlier payment ensures that hospitals will not experience a financial loss for the encounter In which government publication are the details about the various PPS introduced, commented on, and finalized? Federal Register Which of the following concepts is a guiding principle for prospective payment? Payment rates are established in advance of the healthcare delivery and are fixed for the fiscal period to which they apply. The MS-DRG classification system is hierarchical. Which of the following is the highest level in the hierarchy? Major Diagnostic Categories Which PDPM component is adjusted by 18 percent to account for the additional resource intensity required to treat residents living with HIV/AIDS? Nursing Which reimbursement methodology is used for the SNF PPS? Per diem Skilled nursing facility services are covered under Medicare Part A. Under this benefit Medicare beneficiaires are eligible for up to ____ days of SNF-covered services per benefit period?
Bilateral procedures For which clinician is Medicare's resource-based relative value scale resource assignment system modified by a formula that includes base units and time? Anesthesiologists What is the main differentiating factor of an Advanced Alternative Payment Model (APM)? Include significant risk for providers and offer a potential for significant rewards What is the first step in determining reimbursement in the Medicare physician and other professional payment system? Multiply the element RVU by the component GPCI Tatiana, who is a Medicare patient, is seen in at Smiling Faces Physician Practice. The total charge for the office visit is $125.00. Tatiana has previously paid her Medicare Part B deductible. The Medicare physician fee schedule amount for this service is $84.00. The nonparticipating Medicare fee schedule amount for this service is $79.80. Tatiana's provider was a physician assistant that performed the service incident to Dr. Lee, who is a Medicare participating physician. What is the total amount that CMS will reimburse for this encounter? $ Which element of the relative value unit accounts for the physician effort (mental effort and judgement, technical skill, physical effort, and psychological stress)? Physician work Which program is an incentive program for physicians and eligible clinicians that links payment to quality measures and cost-saving goals? Quality Payment Program (QPP) Which element of the relative value unit accounts for the operational costs of delivering healthcare services, such as rent, wages of technical personnel, and supplies and equipment? Practice expense In general, when a nonphysician provider treats a Medicare patient independent of physician supervision (not incident to) how is the MPFS amount adjusted? Decreased 15 percent In a typical acute-care setting, patient registration is located in which revenue cycle component? Front-end
In a typical acute-care setting, patient education of payment policies is located in which revenue cycle area? Front-end In a typical acute-care setting, financial counseling is located in which revenue cycle area? Front-end Who handles submitting a request for a prior authorization for care? provider The amount of money owed by a patient for health care services: Out-of-pocket cost of care Which of the following helps confirm the patient's insurance eligibility and coverage for the service to be provided? Prior authorization The term "price transparency" refers to: Readily available information about the price of services When is the patient's insurance coverage information collected by the provider? Patient registration What is the purpose of a HIPAA authorization form? Allows the provider to use the patient's PHI for insurance claim submission "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" is the definition of: Price transparency Which of the following is the structure of an ICD- 10 - PCS code when N represents a number and A represents and alpha character? NNAANAA Dr. Carter is an orthopedic surgeon. He is a member of a large physician practice in Columbus, Ohio and he has privileges at Memorial Hospital. On average, he admits twelve inpatients for hip replacements surgeries a month at Memorial Hospital. For these inpatient cases which code set does Dr. Carter's office staff utilize to report the hip replacement procedures? CPT Which of the following is not a benefit of single path coding?
Which method is best practice for cost sharing collection? Prior to treatment Which of the following adjudication outcomes results in a full reimbursement amount? Payment The allowable charge is comprised of two parts: the ____________ and the cost sharing amount. Benefit payment The ____________ is the difference between the charge and the allowable charge. Contractual allowance Tiffany works for Super Payer. She is reviewing a suspended claim and the claim attachments that were submitted by the provider. Which revenue cycle process includes this task? Adjudication Which coding position is applicable for a coding professional who performs accuracy reviews, compiles productivity reports, and maintains coding policies and procedures? Coding supervisor How many times is a CDI specialist required to examine a patient's medical record documentation prior to the patient being discharged or transferred? As many times as warranted based on the clinical documentation and circumstances of the admission Which of the following is not a goal of a clinical documentation integrity (CDI) program? Review as many records as possible to achieve a 90 percent review rate. Which coding tool facilitates the incorporation of coded data into the electronic health record? Coding and abstraction platforms Which KPI measure assesses the ability of the coding unit to comply with documentation, coding, and billing requirements? denial rate Simone is a coding manager at Community Hospital. She has been tracking the average minutes it takes her coding staff to code an emergency department encounter. After collecting data for three months, Simone has determined that the average is 13 minutes. If each of her coding professionals are expected to work 400 minutes per workday, what is the coding productivity standard?
30 records per day Which KPI measures the effectiveness of coding management? Case-mix index Which characteristic of high-quality documentation is defined as "the physician has fully addressed all concerns in the patient record; the entry has been signed and dated?" Complete Which category of coding professional has mastery-level skill in multiple code sets? Expert Which type of compliance guidance is used by Medicare to communicate policies and procedures for the specific prospective payment systems' manuals? CMS Transmittals In which improper payment review program are Medicare contractors paid on a contingency fee? Recovery Audit Program Upcoding is: The fraudulent process of submitting codes for reimbursement that indicate more complex or higher-paying services than the patient actually received Which type of compliance guidance is used by Medicare to describe the circumstances under which specific medical supplies, services or procedures are covered nationwide by Medicare. National Coverage Determinations Happy Hospital contracted with Auditors Extraordinaire to perform an outpatient record audit for their clinics. The results of the audit revealed that Happy Hospital's coders were reporting codes that indicated more complex services than those that were documented in the medical record. What type of coding error did Auditors Extraordinaire identify? upcoding Which piece of legislation penalizes federal contractors who knowingly file false or fraudulent claims in order to defraud the US government? False Claims Act Cacey is the coding manager at Memorial Hospital. She is working with compliance to prepare an audit plan for an upcoming inpatient medical record audit. Leadership has been stressing the importance of MS-DRG assignment and the CC/MCC capture rate. Therefore, Cacey is choosing a compliance rate calculation methodology where principal
