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CRCR Exam Multiple Choice,
CRCR Exam Prep, Certified
Revenue Cycle Representative
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 When is the word "SAME" entered on the CMS 1500 billing form in Field 0$?
- Correct answer-When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - Correct answer-Unscheduled patients If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - Correct answer- Neither enrolled not entitled to benefits Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what? - Correct answer-Disclosure rules for consumer credit sales and consumer loans What is a principal diagnosis? - Correct answer-Primary reason for the patient's admission Collecting patient liability dollars after service leads to what? - Correct answer-Lower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - Correct answer-50% of the current deductible amount What service provided to a Medicare beneficiary in a rural health clinic (RHC) is not billable as an RHC services? - Correct answer-Inpatient care
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 The important message from Medicare provides beneficiaries with information concerning what? - Correct answer-Right to appeal a discharge decision if the patient disagrees with the services Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - Correct answer-To improve access to quality healthcare If a patient remains an inpatient of an SNF (skilled nursing facility for more than 30 days, what is the SNF permitted to do? - Correct answer- Submit interim bills to the Medicare program.
- MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - Correct answer-120 days passes, but the claim then be withdrawn from the liability carrier What data are required to establish a new MPI entry? - Correct answer-The patient's full legal name, date of birth, and sex What should the provider do if both of the patient's insurance plans pay as primary? - Correct answer-Determine the correct payer and notify the incorrect payer of the processing error What do EMTALA regulations require on-call physicians to do? - Correct answer- Personally appear in the emergency department and attend to the patient within a reasonable time At the end of each shift, what must happen to cash, checks, and credit card transaction documents? - Correct answer-They must be balanced
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
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 How are patient reminder calls used? - Correct answer-To make sure the patient follows the prep instructions and arrives at the scheduled time for service If a patient declares a straight bankruptcy, what must the provider do? - Correct answer- Write off the account to the contractual adjustment account According to the Department of Health and Human Services guidelines, what is NOT considered income? - Correct answer-Sale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - Correct answer-A condition code What option is an alternative to valid long-term payment plans? - Correct answer-Bank loans What is an advantage of using a collection agency to collect delinquent patient accounts? - Correct answer-Collection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? - Correct answer- revenue codes identify the payer When a patient's illness results in an unusually high amount of medical bills not covered by insurance or other patient pay resources, what type of account is created - Correct answer-catastrophic charity What happens when a patient receives non-emergent services from and out- of-network provider? - Correct answer-Patient payment responsibility is higher 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
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 Third-part administrator (TPA) - Correct answer-Provides services to employers or insurance companies for utilization review, claims payment and benefit design Third-party reimbursement - Correct answer-A general term used for the healthcare benefit payments - used to identify that for benefit plans there are three parties in the transaction Usual, customary, and reasonable (UCR) - Correct answer-Health insurance plan reimbursement methodology that limits payment to the lower billed charges, the provider's customary charge, or the prevailing charge for the service in the community Utilization review - Correct answer-Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Charge - Correct answer-The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Cost - Correct answer-The definition of cost varies by party incurring the expense Price - Correct answer-the total amount a provider expects to be paid by payers and patients for healthcare services Care purchaser - Correct answer-Individual or entity that contributes to the purchase of healthcare services Payer - Correct answer-An organization that negotiates or sets rates for provider services, collects revenue through premium payments or tax dollars, processes provider claims for service, and pays provider claims using collected premium or tax revenues 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
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
The disadvantages of outsourcing include all of the following EXCEPT:
d) Total cash received to date - Correct answer-C
Patients are contacting hospitals to proactively inquire about costs and fees prior to agreeing to service. The problem for hospitals in providing such information is: a) That hospitals don't want to establish a price without knowing if the patient has insurance and how much reimbursement can be expected b) The fact that charge master lists the total charge, not net charges that reflect charges after a payer's contractual adjustment c) That hospitals don't want to be put in the position of "guaranteeing" price without having room for additional charges that may arise in the course of treatment d) Their reluctance to share proprietary information - Correct answer-B 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) Make sure that the attending staff can answer questions and assist in obtaining required patient financial data b) Have a patient financial responsibilities kit ready for the patient, containing all of the required registration forms and instructions 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 - Correct answer-C A comprehensive "Compliance Program" is defined as a) Annual legal audit and review for adherence to regulations b) Educating staff on regulations c) Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met d) The development of operational policies that correspond to regulations - Correct answer-C Case Management requires that a case manager be assigned a) To patients of any physician requesting case management b) To a select patient group c) To every patient d) To specific cases designated by third party contractual agreement - Correct answer-B Pricing transparency is defined as readily available information on the price of healthcare services, that together with other information, help define the
level of value b) Customize health care with a personally chosen mix of providers c) Negotiate the cost of health plan premiums d) Verify the cost of individual clinicians - Correct answer-A 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 a) MSO b) HMO c) PPO d) GPO - Correct answer-B In a Chapter 7 Straight Bankruptcy filing a) The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt b) The court liquidates the debtor's nonexempt property, pays creditors, and begins to pay off the largest claims first. All claims are paid some portion of the amount owed c) The court vacates all claims against a debtor with the understanding that the debtor may not apply for credit without court supervision d) The court establishes a creditor payment schedule with the longest outstanding claims paid first - Correct answer-A The core financial activities resolved within patient access include: a) Scheduling, pre-registration, insurance verification and managed care processing b) Scheduling, insurance verification, clinical discharge processing and payment posting of point of service receipts c) Scheduling, registration, charge entry and managed care processing d) Scheduling, pre-registration, registration, medical necessity screening and patient refunds - Correct answer-A Which of the following is NOT contained in a collection agency agreement? a) A clear understanding that the provider retains ownership of any outsourced activities b) Specific language as to who will pay legal fees, if
needed c) An annual renewal clause d) A mutual hold-harmless clause - Correct answer-D
