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Through what document does a hospital establish compliance standards? ✔✔code of conduct What is the purpose OIG work plant? ✔✔Identify Acceptable compliance programs in various provider setting If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? ✔✔Non-diagnostic service provided on Tuesday through Friday What does a modifier allow a provider to do? ✔✔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 ✔✔They must be billed separately to the part B Carrier what is a recurring or series registration? ✔✔One registration record is created for multiple days of service
HFMA CRCR QUESTIONS AND
ANSWERS GRADED A
What are nonemergency patients who come for service without prior notification to the provider called? ✔✔Unscheduled patients Which of the following statement apply to the observation patient type? ✔✔It is used to evaluate the need for an inpatient admission which services are hospice programs required to provide around the clock patient ✔✔Physician, Nursing, Pharmacy Scheduler instructions are used to prompt the scheduler to do what? ✔✔Complete the scheduling process correctly based on service requeste The Time needed to prepare the patient before service is the difference between the patients arrival time and which of the following? ✔✔Procedure time Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: ✔✔Documentation of the medical necessity for the test
Which of the following is a step in the discharge process? ✔✔Have a case management service complete the discharge plan The hospital has a APC 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 patients benefit package be applied? ✔✔To the approved APC payment rate A patient has met the $200 individual deductible and $900 of the $1000 co-insurance responsibility. The co-insurance rate is 20%. The estimated insurance plan responsibility is $1975.00. What amount of coinsurance is due from the patient? ✔✔$100. When is a patient considered to be medically indigent? ✔✔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? ✔✔Sources of readily available funds , vehicles, campers, boats and saving accounts
If the patient cannot agree to payment arrangements, What is the next option? ✔✔Warn the patient that unpaid accounts are placed with collection agencies for further processing What core financial activities are resolved within patient access? ✔✔scheduling , pre- registration, insurance verification and managed care processing What is an unscheduled direct admission? ✔✔A patient who arrives at the hospital via ambulance for treatment in the emergency department When is it not appropriate to use observation status? ✔✔As a substitute for an inpatient admission Patients who require periodic skilled nursing or therapeutic care receive services from what type of program? ✔✔Home health agency Every patient who is new to the healthcare provider must be offered what? ✔✔A printed copy of the provider privacy notice
Which of the following is true about screening a beneficiary of possible MSP(Medicare secondary payer) situations? ✔✔It is necessary to ask the patient each of the MSP questions Which of the following is not true of Medicare Advantage Plans? ✔✔A patient must have both Medicare Part A and B benefits to be eligible for a Medicare Advantage plan Which of the following is a valid reason for a payer to deny a claim? ✔✔Failure to complete authorization Which of the following statements is NOT a possible consequence of selecting the wrong patient in the MPI(master patient index) ✔✔Claim is paid in full Which of the following statements is true of a Medicare Advantage Plan? ✔✔This plan supplements Part A and Part B benefits Which is the following is not a characteristic of Medicaid HMO plan? ✔✔Medicaid-eligible patients are never required to join a Medicaid HMO plan
Which of the following is violation of the EMTALA? ✔✔Registration staff members routinely contact managed care plans for prior authorizations before the patients is seen by the on duty physician Which of the following statements is true of the important message from Medicare notification requirements? ✔✔Notification can be issued no earlier than 7 days before admission and no more than 2 days before discharge. What is the self pay balance after insurance ✔✔The portion of the adjudicated claim that is due from the patient Which of the following options is an alternative to valid long term payment plans ✔✔Bank loans The patient has the following benefit plan $400 per family member deductible, to a maximum of $1200 per year and $2000 per family member co insurance, to a family maximum of $6000 per year excluding the deductible. Five family members are enrolled in this benefit plan. What is the maximum out of pocket expense that that family could incur during the calendar year? ✔✔$ What type of plan restricts benefits for non-emergency care to approve providers only? ✔✔A POS (point of service )plan
Departments that need to be included in Charge master maintenance include all EXCEPT ✔✔Quality Assurance Using HIPPA standardized transaction sets allow providers to: ✔✔Submit a standardized transaction to any of the health plans with which it conducts business. Which of the following is NOT included in the standardized quality measures? ✔✔Cost of services The ACO investment model will test the use of pre-paid shared savings to: ✔✔Encourage new ACOs to form in rural and underserved areas. Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons on a monthly fee is known as: ✔✔HMO Ambulance services are billed directly to the health plan for: ✔✔Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility.
Any provider that has filed a timely cost report may appeal in an adverse final decision received from the Medicare Administrative Contractor (MAC), the appeal may be filed with: ✔✔The Provider Reimbursement Review Board. For scheduled payments, important revenue cycle activities in the time-of-service stage DO Not include: ✔✔Obtaining or updating patient and guarantor information Hospital can only convert an inpatient case to observation if: ✔✔The hospital utilization review committee determines before the patient is discharged and prior to billing that an observation setting would be more appropriate. Hospital need which of the following information sets to assess a patient's financial status? ✔✔Demographic, Income, Assets and Expenses. HIPAA privacy rules require covered entities to take all, of the following actions EXCEPT: ✔✔Use only designated software platforms to secure patient date.
The soft cost of a dissatisfied customer is: ✔✔The customer passing on information about their negative experience to potential patients or through social media channels. Applying the contracted payment methodology to the total charges yields: ✔✔An estimate price The importance of medical records maintained by HIM is that the patient records: ✔✔Are the primary source for clinical data required for reimbursement by health plans and liability payers Important Revenue Cycle Activities in the pre-service stage include: ✔✔Obtaining or updating patient and guarantor information In the pre-service stage, the cost of the schedule services is identified and the patient's health plan and benefits are used to calculate: ✔✔The amount the patient may be expected to pay after insurance. The disadvantage of outsourcing includes all, of the following Except ✔✔Reduces internal staffing costs and a reliance on outsourced staff.
Marinating routine contact with health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of who: ✔✔Case Management A claim is denied for the following reasons EXCEPT: ✔✔The submitted claim does not have the physician signature All Hospitals are required to establish a written financial assistance policy that applies to: ✔✔All emergency and medically necessary care Examples of ethics violation that impact the revenue cycle include all of the following EXCEPT: ✔✔Seeking payment options for self-pay Verbal orders from a physician for a service(s) are: ✔✔Acceptable if given to "qualified" staff as defined in a hospitals policies and procedures Medicare has established guidelines called Local Coverage Determination (LCD) and National Coverage Determination (NCD) that establish: ✔✔What serviced or healthcare items are covered under Medicare?
Before classifying and subsequently writing off an account to financial assistance or bad debit, the hospital must establish policy define appropriate criteria, implement procedures for identifying accounts and: ✔✔Monitor compliance The Electronic Remittance Advice (ERA) data sets are: ✔✔A standardized for that provides 3rd party payment details to providers The first and most critical step in registering a patient, whether scheduled or unscheduled is: ✔✔Verifying the patient's identification The standard claim form used for the billing by hospitals, nursing facilities, and other inpatient services is called the: ✔✔UB- A four-digit number code established by the National Uniform Billing Committee (NUBC) that categorizes/classifies a line in the charge master is known as: ✔✔Revenue codes Internal controls addressing coding and reimbursement charges are put in place to guard against: ✔✔Compliance fraud by "upcoding"
The 501(R) regulations require non-for-profit providers (501) ©(3) organizations to do which of the following activities: ✔✔Complete a community needs assessment and develop a discount program for patient's balances after insurance payment During pre-registration, a search for the patient's MRI number is initiated using which of the following data sets: ✔✔Patient's full legal name and date of birth or the patient's Social Security number To maximize the value derived from customer complaints, all consumer complaints should be: ✔✔Tracked and shared to improve the customer experience The Business ethics, or organizational ethics represent: ✔✔The principles and standards by which organizations operate Providers are advised that it is best to establish patient financial responsibility and assistance policies and make sure they are followed internally and by: ✔✔Third-party payers The advantage to using a third-part, collection agency includes all of the following EXCEPT: ✔✔Providers pay pennies on each dollar collected.
The fundamental approach in managing denials is: ✔✔To analyze the type and sources of denials and consider process changes to eliminate further denials The first thing a health plan does when processing a claim is: ✔✔Check if the patient is a health plan beneficiary and what is the coverage Outsourcing options should be evaluated as ✔✔Any other business service purchase Insurance verification results in which of the following: ✔✔The accurate identification of the patient's eligibility and benefits EMTLA and HFMA best practices specify that in an Emergency Department setting: ✔✔No patient financial discussions should occur before a patient is screened and stabilized he HCCAHPS (Hospital Consumer Assessment of Healthcare Provider's and Systems) initiative was launched to: ✔✔Provide a standardized method for evaluation patients' perspective on hospital care
All of the following are potential causes of credit balances EXCEPT: ✔✔A patient's choice to build up a credit against future medical bills Medicare will only pay for tests and services that: ✔✔Can be demonstrated as necessary This was developed to promote and ensure healthcare quality and value and also to protect consumers and workers in the healthcare system. This directive is called: ✔✔Joint Commission for Acceleration of Healthcare Organizations (JCAHO) safety standards It is important to calculate reserves to ensure: ✔✔A stable financial operations and accurate financial reporting An advantage of a pre-registration program in ✔✔The opportunity to reduce processing times at the time of service To be eligible for Medicaid, an individual must: ✔✔Meet income and asset requirements The patient discharge process begins when: ✔✔The physician writes the order
