What are collection agency fees based on?
A percentage of dollars collected
Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule?
Birthday
In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers?
Case rates
What customer service improvements might improve the patient accounts department?
Holding staff accountable for customer service during performance reviews
What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do?
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?
Bad debt adjustment
What is the initial hospice benefit?
Two 90-day periods and an unlimited number of subsequent periods
When does a hospital add ambulance charges to the Medicare inpatient claim?
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?
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
They are not being processed in a timely manner
What is an advantage of a preregistration program?
It reduces processing times at the time of service
What are the two statutory exclusions from hospice coverage?
Medically unnecessary services and custodial care
What core financial activities are resolved within patient access?
Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts
What statement applies to the scheduled outpatient?
The services do not involve an overnight stay
How is a mis-posted contractual allowance resolved?
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?
Observation
Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what?
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$?
When the patient is the insured
What are non-emergency patients who come for service without prior notification to the provider called?
Unscheduled patients
If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber’s spouse?
Neither enrolled not entitled to benefits
Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what?
Disclosure rules for consumer credit sales and consumer loans
What is a principal diagnosis?
Primary reason for the patient’s admission
Collecting patient liability dollars after service leads to what?
Lower accounts receivable levels
What is the daily out-of-pocket amount for each lifetime reserve day used?
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?
Inpatient care
What code indicates the disposition of the patient at the conclusion of service?
Patient discharge status code
What are hospitals required to do for Medicare credit balance accounts?
They result in lost reimbursement and additional cost to collect
When an undue delay of payment results from a dispute between the patient and the third party payer, who is responsible for payment?
Patient
Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include:
A valid CPT or HCPCS code
With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what?
Access their information and perform functions on-line
What date is required on all CMS 1500 claim forms?
onset date of current illness
What does scheduling allow provider staff to do
Review appropriateness of the service request
What code is used to report the provider’s most common semiprivate room rate?
Condition code
Regulations and requirements for coding accountable care organizations, which allows providers to begin creating these organizations, were finalized in:
2012
What is a primary responsibility of the Recover Audit Contractor?
To correctly identify proper payments for Medicare Part A & B claims
How must providers handle credit balances?
Comply with state statutes concerning reporting credit balance
Insurance verification results in what?
The accurate identification of the patient’s eligibility and benefits
What form is used to bill Medicare for rural health clinics?
CMS 1500
What activities are completed when a scheduled pre-registered patient arrives for service?
Registering the patient and directing the patient to the service area
In addition to being supported by information found in the patient’s chart, a CMS 1500 claim must be coded using what?
HCPCS (Healthcare Common Procedure Coding system)
What results from a denied claim?
The provider incurs rework and appeal costs
Why does the financial counselor need pricing for services?
To calculate the patient’s financial responsibility
What type of provider bills third-party payers using CMS 1500 form
Hospital-based mammography centers
How are disputes with nongovernmental payers resolved?
Appeal conditions specified in the individual payer’s contract
The important message from Medicare provides beneficiaries with information concerning what?
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?
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?
Submit interim bills to the Medicare program.
- MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens?
120 days passes, but the claim then be withdrawn from the liability carrier
What data are required to establish a new MPI entry?
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?
Determine the correct payer and notify the incorrect payer of the processing error
What do EMTALA regulations require on-call physicians to do?
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?
They must be balanced
What will cause a CMS 1500 claim to be rejected?
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?
The cost of the test
how are HCPCS codes and the appropriate modifiers used?
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?
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?
Patient arrival processing is expedited, reducing wait times and delays
What is a characteristic of a managed contracting methodology?
Prospectively set rates for inpatient and outpatient services
What do the MSP disability rules require?
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?
Blue Cross and blue Shield
What is true about screening a beneficiary for possible MSP situations?
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?
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?
Receive a fixed for specific procedures
What will comprehensive patient access processing accomplish?
Minimize the need for follow-up on insurance accounts
Through what document does a hospital establish compliance standards?
Code of conduct
How does utilization review staff use correct insurance information?
To obtain approval for inpatient days and coordinate services
When is it not appropriate to use observation status?
As a substitute for an inpatient admission
What is a serious consequence of misidentifying a patient in the MPI?
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?
Redirect the patient to the patient access department for registration
What process can be used to shorten claim turnaround time?
Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail
How are patient reminder calls used?
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?
Write off the account to the contractual adjustment account
According to the Department of Health and Human Services guidelines, what is NOT considered income?
Sale of property, house, or car
The situation where neither the patient nor spouse is employed is described to the patient using:
A condition code
What option is an alternative to valid long-term payment plans?
Bank loans
What is an advantage of using a collection agency to collect delinquent patient accounts?
Collection agencies collect accounts faster than hospital does
What statement DOES NOT apply to revenue codes?
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
catastrophic charity
What happens when a patient receives non-emergent services from and out-of-network provider?
Patient payment responsibility is higher
Every patient who is new to the healthcare provider must be offered what?
A printed copy of the provider’s privacy notice
How may a collection agency demonstrate its performance?
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?
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?
The UB-04 and the CMS 1500
Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information?
Obtain the required demographic and insurance information before services are rendered
what protocol was developed through the Patient Friendly Billing Project?
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?
Ask if the patient’s current services was accident related
What is a valid reason for a payer to delay a claim?
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
They must be combined with the inpatient bill and paid under the MS-DRG system
What do large adjustments require?
Manager-level approval
What items are valid identifiers to establish a patient’s identification?
Photo identification, date of birth, and social security number
What must a provider do to qualify an account as a Medicare bad debts?
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?
Site-of-service limitation
What is an example of an outcome of the Patient Friendly Billing Project?
Redesigned patient billing statements using patient-friendly language
What statement describes the APC (Ambulatory payment classification) system?
APC rates are calculated on a national basis and are wage-adjusted by geographic region
What is a benefit of insurance verification?
Pre-certification or pre-authorization requirements are confirmed
What is an effective tool to help staff collect payments at the time of service?
Develop scripts for the process of requesting payments
What is a benefit of electronic claims processing?
Providers can electronically view patient’s eligibility
What does Medicare Part D provide coverage for?
Prescription drugs
What are some core elements of a board-approved financial policy
Charity care, payment methods, and installment payment guidelines
What circumstance would result in an incorrect nightly room charge?
If the patient’s discharge, ordered for tomorrow, has not been charted
What is NOT a typical charge master problem that can result in a denial?
Does not include required modifiers
Access
An individual’s ability to obtain medical services on a timely and financially acceptable level
Administrative Services Only (ASO)
Usually contracted administrative services to a self-insured health plan
Case management
The process whereby all health-related components of a case are managed by a designated health professional. Intended to ensure continuity of healthcare accessibility and services
Claim
A demand by an insured person for the benefits provided by the group contract
Coordination of benefits (COB)
a typical insurance provision that determines the responsibility for primary payment when the patient is covered by more than one employer-sponsored health benefit program
Discounted fee-for-service
A reimbursement methodology whereby a provider agrees to provide service on a fee for service basis, but the fees are discounted by certain packages
Eligibility
Patient status regarding coverage for healthcare insurance benefits
First dollar coverage
A healthcare insurance policy that has no deductible and covers the first dollar of an insured’s expenses
Gatekeeping
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
an insurance company that provides for the delivery or payment of healthcare services
Indemnity insurance
negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations
Medically necessary
Healthcare services that are required to preserve or maintain a person’s health status in accordance with medical practice standards
Out-of-area benefits
healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO
Out-of-pocket payments
Cash payments made by the insured for services not covered by the health insurance plan
Pre-admission review
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
A restriction on payments for charges directly resulting from a pre-existing health conditions
Same-day admission
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
Large employers who assume direct responsibility or risk for paying employees’ healthcare without purchasing health insurance
Subrogation
Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient’s medical expenses
Subscriber
An employer, a union, or an association that contracts with an insurance company for the healthcare plan it offers to eligible employees
Sub-specialist
A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery
Third-part administrator (TPA)
Provides services to employers or insurance companies for utilization review, claims payment and benefit design
Third-party reimbursement
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)
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
Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients
Charge
The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid
Cost
The definition of cost varies by party incurring the expense
Price
the total amount a provider expects to be paid by payers and patients for healthcare services
Care purchaser
Individual or entity that contributes to the purchase of healthcare services
Payer
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
An entity, organization, or individual that furnishes a healthcare service
Out of pocket payment
The portion of the total payment for medical services and treatment for which the patient is responsible, including copayments, coinsurance, and deductibles
Price transparency
In health care, 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
Value
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?
Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations
FERA
Fraud Enforcement and Recovery act
ESRD
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?
Mitigate potential fraud and abuse in the industry-specific key risk areas
What is important about an effective corporate compliance program?
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
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?
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.
TRUE
The OIG has issued compliance guidance/model compliance plans for all of the following entities:
hospices. physician practices. ambulance providers
Providers who are found to be in violation of CMS regulations are subject to:
Corporate integrity agreements
What MSP situation requires LGHP
Disability
The disadvantages of outsourcing include all of the following EXCEPT:
a) The impact of customer service or patient relations
b) The impact of loss of direct control of accounts receivable services
c) Increased costs due to vendor ineffectiveness
d) Reduced internal staffing costs and a reliance on outsourced staff
D
The Medicare fee-for service appeal process for both beneficiaries and providers
includes all of the following levels EXCEPT:
a) Medical necessity review by an independent physician’s panel
b) Judicial review by a federal district court
c) Redetermination by the company that handles claims for
Medicare
d) Review by the Medicare Appeals Council (Appeals Council)
B
Business ethics, or organizational ethics represent:
a) The principles and standards by which organizations operate
b) Regulations that must be followed by law
c) Definitions of appropriate customer service
d) The code of acceptable conduct
A
A portion of the accounts receivable inventory which has NOT qualified for billing
includes:
a) Charitable pledges
b) Accounts created during pre-registration but not activated
c) Accounts coded but held within the suspense period
d) Accounts assigned to a pre-collection agency
A
Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) are
Medicare established guideline(s) used to determine:
a) Medicare and Medicaid provider eligibility
b) Medicare outpatient reimbursement rates
c) Which diagnoses, signs, or symptoms are reimbursable
d) What Medicare reimburses and what should be referred to
Medicaid
C
Days in A/R is calculated based on the value of:
a) The total accounts receivable on a specific date
b) Total anticipated revenue minus expenses
c) The time it takes to collect anticipated revenue
d) Total cash received to date
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
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
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
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
B
Pricing transparency is defined as readily available information on the price of
healthcare services, that together with other information, help define the value of those
services and enable consumers to
a) Identify, compare, and choose providers that offer the desired
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
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
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
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
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
D
Maintaining routine contact with the health plan or liability payer, making sure all
required information is provided and all needed approvals are obtained is the
responsibility of:
a) Patient Accounts
b) Managed Care Contract Staff
c) HIM staff
d) Case Management
D
What is required for the UB-04/837-I, used by Rural Health Clinics to generate payment
from Medicare?
a) Revenue codes
b) Correct Part A and B procedural codes
c) The CMS 1500 Part B attachment
d) Medical necessity documentation
A
Before classifying and subsequently writing off an account to financial assistance or bad
debt, the hospital must establish policy, define appropriate criteria, implement
procedures for identifying and processing accounts:
a) Monitor compliance
b) Have the account triaged for any partial payment possibilities
c) Assist in arranging for a commercial bank loan
d) Obtain the patients income tax statements from the prior 2 years
A
For routine scenarios, such as patients with insurance coverage or a known ability to
pay, financial discussions:
a) Are optional
b) Should take place between the patient or guarantor and properly
trained provider representatives
c) May take place between the patient and discharge planning
d) Are focused on verifying required third-party payer information
B
The purpose of a financial report is to:
a) Provide a public record, if reqluested
b) Present financial information to decision makers
c) Prepare tax documents
d) Monitor expenses
B
Which statement is an EMTALA (Emergency Medical Treatment and Active Labor Act)
violation?
a) Registration staff may routinely contact managed are plans for
prior authorizations before the patient is seen by the on-duty
physician
b) Initial registration activities may occur so long as these activities
do not delay treatment or suggest that treatment with not be
provided to uninsured individuals
c) Co-payments may be collected at the time of service once the
medical screening and stabilization activities are completed
d) Signage must be posted where it can be easily seen and read by
patients
A
A claim is denied for the following reasons, EXCEPT:
a) The health plan cannot identify the subscriber
b) The frequency of service was outside the coverage timeline
c) The submitted claim does not have the physicians signature
d) The subscriber was not enrolled at the time of service
C
Any provider that has filed a timely cost report may appeal an adverse final decision
received from the Medicare Administrative Contractor (MAC). This appeal may be filed
with
a) A court appointed federal mediator
b) The Department of Health and Human Services Provider Relations
Division
c) The Office of the Inspector General
d) The Provider Reimbursement Review Board
D
Charges, as the most appropriate measurement of utilization, enables
a) Generation of timely and accurate billing
b) Managing of expense budgets
c) Accuracy of expense and cost capture
d) Effective HIM planning
???Number 24???
Ambulance services are billed directly to the health plan for
a) All pre-admission emergency transports
b) 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
c) The portion of the bill outside of the patient’s self-pay
d) Transports deemed medically necessary by the attending
paramedic-ambulance crew
C
An individual enrolled in Medicare who is dissatisfied with the government’s claim
determination is entitled to reconsideration of the decision. This type of appeal is
known as
a) A beneficiary appeal
b) A Medicare supplemental review
c) A payment review
d) A Medicare determination appeal
A
The nuanced data resulting from detailed ICD-10 coding allows senior leadership to
work with physicians to do all of the following EXCEPT:
a) Drive significant improvements in the areas of quality and the
patient experience
b) Embrace new reimbursement models
c) Improve outcomes
d) Obtain higher compensation for physicians
D
Duplicate payments occur:
a) When providers re-bill claims based on nonpayment from the
initial bill submission
b) When service departments do not process charges with the
organization’s suspense days
c) When the payer’s coordination of benefits is not captured
correctly at the time of patient registration
d) When there are other healthcare claims in process and the
anticipated deductibles and co-insurance amounts still show open
but will be met by the in-process claims
a
The Affordable Care Act legislated the development of Health Insurance Exchanges,
where individuals and small businesses can
a) Purchase qualified health benefit plans regardless of insured’s
health status
b) Obtain price estimates for medical services
c) Negotiate the price of medical services with providers
d) Meet federal mandates for insurance coverage and obtain the
corresponding tax deduction
A
The most common resolution methods for credit balances include all of the following
EXCEPT:
a) Designate the overpayment for charity care
b) Submit the corrected claim to the payer incorporating credits
c) Either send a refund or complete a takeback form as directed by
the payer
d) Determine the correct primary payer and notify incorrect payer of
overpayment
A
EFT (electronic funds transfer) is
a) An electronic claim submission
b) The record of payments in the hospital’s accounting system
c) An electronic confirmation that a payment is due
d) An electronic transfer of funds from payer to payee
D
Revenue cycle activities occurring at the point-of-service include all of the following
EXCEPT:
a) The monitoring of charges
b) The provision of case management and discharge planning
services
c) Providing charges to the third-party payer as they are incurred
d) The generation of charges
C
Medicare beneficiaries remain in the same “benefit period”
a) Up to hospitalization discharge
b) Until the beneficiary is “hospitalization and/or skilled nursing
facility-free” for 60 consecutive days
c) Each calendar year
d) Up to 60 days
B
Key Performance Indicators (KPIs) set standards for accounts receivables (A/R) and
a) Provide evidence of financial status
b) Provide a method of measuring the collection and control of A/R
c) Establish productivity targets
d) Make allowance for accurate revenue forecasting
B
Recognizing that health coverage is complicated and not all patients are able to navigate
this terrain, HFMA best practices specify that
a) The patient accounts staff have someone assigned to research
coverage on behalf of patients
b) Patients should be given the opportunity to request a patient
advocate, family member, or other designee to help them in these
discussions
c) Patient coverage education may need to be provided by the
health plan
d) A representative of the health plan be included in the patient
financial responsibilities discussion
B
When there is a request for service, the scheduling staff member must confirm the
patient’s unique identification information to
a) Check if there is any patient balance due
b) Verify the patient’s insurance coverage if the patient is a returning
customer
c) Confirm that physician orders have been received
d) Ensure that she/he accesses the correct information in the
historical database
D
Once the price is estimated in the pre-service stage, a provider’s financial best practice
is to
a) Explain to the patient their financial responsibility and to
determine the plan for payment
b) Allow the patient time to compare prices with other providers
c) Lock-in the prices
d) Have another employee double check the price estimate
A
What type of account adjustment results from the patient’s unwillingness to pay a self-
pay balance?
a) Charity adjustment
b) Bad debt adjustment
c) Contractual adjustment
d) Administrative adjustment
B
All of the following are conditions that disqualify a procedure or service from being paid
for by Medicare EXCEPT
a) Medically unnecessary
b) Not delivered in a Medicare licensed care setting
c) Offered in an outpatient setting
d) Services and procedures that are custodial in nature
D
All of the following are forms of hospital payment contracting EXCEPT
a) Contracted Rebating
b) Per Diem Payment
c) Fixed Contracting
d) Bundled Payment
A
Overall aggregate payments made to a hospice are subject to a computed “cap amount”
calculated by:
a) The Center for Medicare and Medicaid Services (CMS)
b) Each state’s Medicaid plan
c) Medicare
d) The Medicare Administrative Contractor (MAC) at the end of the
hospice cap period
D
With the advent of the Affordable Care Act Health Insurance Marketplaces and the
expansion of Medicaid in some states, it is more important than ever for hospitals to
a) Reschedule the visit for non-payment of a prior balance
b) Strictly limit charity care and bad-debt
c) Collect patient’s self-pay and deductibles in the first encounter
d) Assist patients in understanding their insurance coverage and
their financial obligation
D
A nightly room charge will be incorrect if the patient’s
a) Discharge for the next day has not been charted
b) Condition has not been discussed during the shift change report
meeting
c) Pharmacy orders to the ICU have not been entered in the
pharmacy system
d) Transfer from ICU (intensive care unit) to the Medical/Surgical
floor is not reflected in the registration system
D
Which of the following is required for participation in Medicaid?
a) Meet income and assets requirements
b) Meet a minimum yearly premium
c) Be free of chronic conditions
d) Obtain a health insurance policy
A
HFMA best practices call for patient financial discussions to be reinforced
a) By issuing a new invoice to the patient
b) By copying the provider’s attorney on a written statement of
conversation
c) By obtaining some type of collateral
d) By changing policies to programs
B
A Medicare Part A benefit period begins:
a) With admission as an inpatient
b) The first day in which an individual has not been a hospital
inpatient not in a skilled nursing facility for the previous 60 days
c) Upon the day the coverage premium is paid
d) Immediately once authorization for treatment is provided by the
health plan
A
If further treatment can only be provided in a hospital setting, the patient’s condition
cannot be evaluated and/or treated within 24 hours, or if there is not an anticipation of
improvement in the patient’s condition with 24 hours, the patient
a) Will remain in observation for up to 72 hours after which the
patient is admitted as an inpatient
b) Will be admitted as an inpatient
c) Will be discharged and if needed, designated to a priority one
outpatient status
d) Will have his/her case reviewed by the attending physician, a
consulting physician and the primary care physician and a future
course of care will then be determined
B
It is important to have high registration quality standards because
a) Incomplete registrations will trigger exclusion from Medicare
participation
b) Incomplete registrations will raise satisfaction scores for the
hospital
c) Inaccurate registration may cause discharge before full treatment
is obtained
d) Inaccurate or incomplete patient data will delay payment or
cause denials
D
Medicare will only pay for tests and services that
a) Constitute appropriate treatment and are fairly priced
b) Have solid documentation
c) Can be demonstrated as necessary
d) Medicare determines are “reasonable and necessary”
D
Room and bed charges are typically posted
a) From case management reports generated for contracted payers
b) Through the case management daily resource report
c) At the end of each business day
d) From the midnight census
D
The process of creating the pre=registration record ensures
a) Ability to pursue extraordinary collection activities
b) Early and productive communication with a third-party payer
c) Accurate billing
d) That access staff will have the compete and valid information
needed to finalize any remaining pre-access activities
C
Once the EMTALA requirements are satisfied
a) Third-party payer information should be collected from the
patient and the payer should be notified of the ED visit
b) The patient then assumes full liability for services unless a third-
party is notified or the patient applies for financial assistance with
the first 48 hours
c) The remaining registration processing is initiated at the bedside or
in a registration area
d) An initial registration records is completed so that the proper
coding can be initiated
C
This directive 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
a) Payer quality monitoring
b) Medicare patient and staff safety standards
c) Joint Commission for Accreditation of Healthcare Organizations
(JCAHO) safety
d) Patient bill of rights
D
A scheduled inpatient represents an opportunity for the provider to do which of the
following?
a) Refer the patient to another location with the health system
b) Comply with EMTALA (Emergency Medical Treatment and Labor Act)
requirements before service
c) Complete registration and insurance approval before service
d) Register the patient after he or she is placed in a bed on that service
unit.
C
The first and most critical step in registering a patient, whether scheduled or
unscheduled, is
a) Having the patient initial the HIPAA privacy statement
b) Verifying insurance to activate the patient medical record
c) Verifying the patient’s identification
d) Check the schedule for treatment availability
C
The legal authority to request and analyze provider clam documentation to ensure that
IPPS services were reasonable and necessary is given to
a) Recovery Audit Contractors (RAC)
b) The Office of the U.S. Inspector General (OIG)
c) All health plans
d) State insurance commissioners
B
An advantage of a pre-registration program is
a) The opportunity to reduce processing times at the time of service
b) The ability to eliminate no-show appointments
c) The opportunity to reduce the corporate compliance failures
within the registration process
d) The marketing value of such a program
C
Claims with dates of service received later than one calendar year beyond the date of
service, will be
a) Denied by Medicare
b) The provider’s responsibility but can be deemed charity care
c) Fully paid with interest
d) The full responsibility of the patient.
A
This concept encompasses all activities required to send a request for payment to a
third-party health plan for payment of benefits
a) Third-party invoicing
b) Account resolution
c) Claims processing
d) Billing
C
The ACO investment model will test the use of pre-paid shared savings to
a) Raise quality ratings in designated hospitals.
b) Encourage new ACOs to form in rural and underserved areas
c) Attract physicians to participate in the ACO payment system
d) Invest in treatment protocols that reduce costs to Medicare
B
Chapter 13 Bankruptcy, debtor rehabilitation, is a court proceeding
a) That establishes a payment priority order to creditors’ claims
b) That classifies the debtor as eligible for government financial assistance
for housing, medical treatment and food as debts are paid
c) That creates a clear court-supervised payment accountability plan going
forward
d) That reorganizes a debtor’s holdings and instructs creditors to look to the
debtor’s future earnings for payment
D
HFMA’s patient financial communication best practices specify that patients should be
told about the types of services provided and
a) A satisfaction survey regarding clinical service providers
b) The price of service to their covering health plan
c) The service providers that typically participate in the service, e.g.,
radiologists, pathologists, etc.
d) An expiration of why a specific service is not provided
C
The important Message from Medicare provides beneficiaries information concerning
their
a) Understanding of billing issues and the deductibles and/or co-insurance
due for the current visit
b) Right to refuse to use lifetime reserve days for the current stay
c) Right to appeal a discharge decision if the patient disagrees with the plan
d) Obligation to reimburse the hospital for any services not covered by the
Medicare program
C
All of the following are potential causes of credit balances EXCEPT
a) Duplicate payments
b) Primary and secondary payers both paying as primary
c) Inaccurate upfront collections based on incorrect liability estimates
d) A patient’s choice to build up a credit against future medical bills
D
Medicare Part B has an annual deductible, and the beneficiary is responsible for
a) A co-insurance payment for all Part B covered services
b) Physicians office fees
c) Tests outside of an inpatient setting
d) Prescriptions
A
The importance of medical records being maintained by HIM is that the patient records
a) Are the primary source for clinical data required for reimbursement by
health plans and liability payers
b) Are the strongest evidence and defense in the event of a Medicare audit
c) Are evidence used in assessing the quality of care
d) Are the evidence cited in quality review
A
A decision on 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 home care coverage
b) Current medical needs
c) The likelihood of an adverse event occurring to the patient
d) The patient’s medical history
A
Medicare has established guidelines called the Local Coverage Determinations (LCD) and
National Coverage Determinations (NCD) that establish
a) Provider and physician reimbursement for specific diagnoses and tests
b) Prospective Medicare patient financial responsibilities for a given
diagnosis
c) Reasonable and customary prices for services in a given area
d) What services or healthcare items are covered under Medicare
D
What are some core elements if a board-approved financial assistance policy?
a) Payment requirements, staffing hours, and admission policies
b) Case management, payment methods, and discharge policies
c) Deposit requirements, pre-registration calling hours, and charity care
policy
d) Eligibility, application process, and nonpayment collection
activities
D
The ICD-10 codes set and CPT/HCPCS code sets combines provide
a) Pricing floors for services
b) The financial data required for activity-based costing
c) Patients an overview of services covered by their health insurance plan
d) The specificity and coding needed to support reimbursement claims
D
A recurring/series registration is characterized by
a) A creation of multiple registrations for multiple services
b) The creation of one registration record for multiple days of service
c) The creation of multiple patient types for one date of service
d) The creation of one registration record per diagnosis per visit
B
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?
a) Complete course of treatment
b) Medical screening and stabilizing treatment
c) Admission to observation status
d) Transfer to another facility
B
In resolving medical accounts, a law firm may be used as:
a) An independent auditor of a financial assistance policy
b) Legal counsel to patients regarding financing options
c) An independent broker of patient financial assistance from banks
d) A substitute for a collection agency
D
The unscheduled “direct” admission represents a patient who:
a) Is admitted from a physician’s office on an urgent basis
b) Arrives at the hospital via ambulance for treatment in the emergency room
c) Is an ambulatory patient who collapses in the hospital lobby
d) Arrives on the medical helicopter for trauma services
A
In the balance resolution process, providers should:
a) Stress to the patient that serious consequences may result from refusal to pay
b) Remind the patient of their legal responsibility to pay the balance due
c) Ask the patient if he or she would like to receive information about
payment options and supportive financial assistance programs
d) Tag the patients record for possible financial assistance for bad debt
C
Which of the following in NOT included in the Standardized Quality Measures
a) Clinical outcomes
b) Patient perceptions
c) Health care processes
d) Cost of services
D
In the pre-service stage, the requested service is screened for medical necessity, health
plan coverage and benefits are verified and:
a) Billing authorization is signed by the patient
b) The patient signs the consents for treatment
c) The patient signs a statement attesting an understanding and acceptance of payment
policies
d) Pre-authorization are obtained
D
Improving the overall patient experience requires revenue cycle leadership and staff to
simultaneously be:
a) Clear on policies and consistent in applying the policies
b) Careful in screening patient demands
c) Monitoring the costs and charges the patient incurs
d) Inquisitive, responsive and flexible
A
Hospitals need which of the following information sets to assess a patient’s financial
status:
a) Income, expenses, debt
b) Patient and guarantor’s income, expenses and assets
c) Income, expenses and capacity to take on more debt
d) Assets liquidity, Income, expenses, credit worthiness
B
For scheduled patients, important revenue cycle activities I the Time of Service stage DO
NOT INCLUDE:
a) Pre-registration record is activated, consents are signed, and co-payment is collected
b) Positive patient identification is completed, and patient is given an armband
c) Final bill is presented for payment
d) Preprocessed patients may report to a designated “express arrival” desk
C
The Electronic Remittance Advice (ERA) data set is :
a) Used for Electronic Funds Transfers between hospitals and a bank
b) A standardized form that provides 3rd party payment details to
providers
c) Required for annual Medicare quality reporting forms
d) Safeguards the Electronic claims process
B
Appropriate training for patient financial counseling 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 records
d) Available patient financing options
C
All of the following information should be reviewed as part of schedule finalization
EXCEPT:
a) The results of any and all test
b) The service to be provided
c) The arrival time and procedure time
d) The patient’s preparation instructions
A
Indemnity plans usually reimburse:
a) Only for contracted Services
b) A claim up to 80% of the charges
c) A certain percentage of the charges after the patient meets the
policy’s annual deductible
d) A patient for out-of-pocket charges
C
Because 501(r) regulations focus on identifying potential eligible financial assistants
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 schedule
d) Expedite payment processing of normal accounts receivable to protect cash flow
B
Which option is a benefit of pre-registering a patient for services
a) The patient arrival process is expedited, reducing wait times and
delays
b) The verification of insurance after completion of the services
c) Service departments have the ability to override schedules and block time to reduce
testing volume
d) The patient receiving multiple calls from the provider
A
HIPPA had adopted Employer Identification Numbers (EIN) to be used in standard
transactions to identify the employer of an individual described in a transaction EIN’s are
assigned by
a) The Social Security Administration
b) The US department of the Treasury
c) The United States department of labor
d) The Internal Revenue Service
D
The nightly room charge will be incorrect if the patient’s
a) Transfer from ICU to the Medical/Surgical floor is not reflected in the
registration system.
b) Pharmacy orders to the ICU have not been entered into the pharmacy system
c) Condition has not been discussed during the shift change report meeting
d) Discharge for the next day has not been charted
A
With any remaining open balances, after insurance payments have been posted, the
account financial liability is
a) Written off as bad debt
b) Potentially transferred to the patient
c) Sold to a collection agency
d) Treated as the cost of doing business
B
When there is a request for service the scheduling staff member must confirm the
patient’s
unique identification information to:
a) Verify the patient’s insurance coverage if the patient is a returning customer
b) Ensure that she/he accesses the correct information in the historical
database
c) Confirm that physician orders have been received
d) Check if any patient balance due
B
Identifying the patient, in the MPI, creating the registration record, completing medical
necessity screening, determining insurance eligibility and benefits resolving managed
care, requirements and completing financial education/resolution are all
a) The data collection steps for scheduling and pre-registering a patient
b) Registration steps that must be completed before any medical services are provided
c) The steps mandated for billing Medicare Part A
d) The process of closing an account
A
Insurance verification results in which of the following
a) The accurate identification of the patient’s eligibility and benefits
b) The consistent formatting of the patient’s name and identification number
The resolution of managed care and billing requirements
The identification of physician fee schedule amounts and the NPI (national provider
identifier) numbers
A
A four digit number code established by the National Uniform Billing Committee (NUBC)
that categorizes/classifies a line item in the charge master is known as
a) HCPCs codes
b) ICD-10 Procedural codes
c) CPT codes
d) Revenue codes
D
The importance of Medical records being maintained by HIM is that the patient records:
a) Are evidence used in assessing the quality of care
b) Are the primary source for clinical data required for reimbursement
by health plans and liability payers
C) Are the strongest evidence and defense in the event of a Medicare Audit
d) Are the evidence cited in quality review
B
Medicare patients are NOT required to produce a physician order to receive which of
these services
a) Diagnostic Mammography, flu vaccine, or B-12 shots
b) Diagnostic Mammography, flu vaccine, or pneumonia vaccine
c) Screening Mammography, flu vaccine or pneumonia vaccine
d) Screening Mammography, flu vaccine or B-12 shots
C
Patients should be informed that costs presented in a price estimate may
a) Vary from estimates, depending on the actual services performed
b) Be guaranteed if the patient satisfies all patient financial responsibilities at the time
of registration
c) Be lower as price estimates use the highest market price
d) Only determine the percentage of the total that the patient is responsible for and not
the actual cost
A
Ambulance services are billed directly to the health plan for
a) All pre-admission emergency transports
b) Transport deemed medically necessary by the attending paramedic-ambulance crew
c) 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
d) The portion of the bill outside of the patient’s self-pay
C
In Chapter 7 straight bankruptcy filling
a) The court establishes a creditor payment schedule with the longest outstanding claims
paid first
b) The court liquidates the debtor’s nonexempt property, pays creditors,
and discharges the debtor from the debt
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 liquidates the debtor’s nonexempt property, pays creditors, and begins to
pay off the largest claims first. All claims are paid some portions of the amount owed.
B
The activity which results in the accurate recording of patient bed and level of care
assessment, patient transfer and patient discharge status on a real-time basis is known
as
a) Utilization review
b) Case management
c) Census management
d) Patient through-put
B
Which of the following is required for participation in Medicaid
a) Obtain a supplemental health insurance policy
b) Meet income and assets requirements
c) Meet a minimum yearly premium
d) Be free of chronic conditions
B
When primary payment is received, the actual reimbursement
a) Is compared to the expected reimbursement
b) Is recorded by Patient Accounting and the patient’s account is the closed
c) Is compared to the expected reimbursement, the remaining
contractual adjustments are posted, and secondary claims are
submitted
d) Trigger that the secondary claims can then be prepared.
C
Days in A/R is calculated based on the value of
a) Total cash received to date
b) The time it takes to collect anticipated revenue
c) The total accounts receivable on a specific date
d) Total anticipated revenue minus expenses
C
All of the following are forms of hospital payment contracting EXCEPT
a) Per diem payment
b) Bundled Payment
c) Fixed Contracting
d) Contracted Rebating
D
The standard claim form used for billing by hospitals, nursing facilities, and other in-
patient
services is called the
a) UB-04
b) 1500
c) COST REPORT
d) REMITTANCE NOTICE
A
To maximize the value derived from customer complaints, all consumer complaints should
be
a) Responded to within two business days
b) Tracked and shared to improve the customer experience
c) Handled by a specially trained “service recovery” team
d) Brought immediately to management’s attention
A
The HCAHPS (hospital consumer assessment of healthcare providers and systems)
initiative
was launched to
a) Gather national date on overall trust in the nation’s health care system
b) Create a national database on physician quality
c) Provide a standardized method for evaluating patient’s perspective on
hospital care. ?
d) Provide data for building shared savings reimbursement for quality procedures.
C
Health Plan Contracting Departments do all of the following EXCEPT
a) Establish a global reimbursement rate to use with all third-party payer
b) Review all managed care contracts for accuracy for loading 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
A
The benefit of 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 Medicare-coverage healthcare through
the plan and do not need to worry about “part a” or “part b” benefits
d) Patients receive significant discounting on services contracted by the federal
government
C
Once the EMTALA requirements are satisfied
a) Third-party payer info should be collected from the pt and the payer
should be notified of the ED visit
b) An initial registration record is completed so that the proper coding can be initiated
c) The pt then assumes full liability for services unless a third-party payer is notified or
the pt applies for financial assistance within the first 48 hours
d) The remaining registration processing is initiated either at the bedside or In a
registration area
A
The soft cost of a dissatisfied customer is
a) The “cost” of staff providing extra attention in trying to perform service recovery
b) The customer passing on info about their negative experience to
potential pts or through social media channels
c) Potentially negative treatment outcomes leading to expanding length-of-stay
d) Lowered quality outcomes for the dissatisfied pt
B
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 pt
A
In a self-insured (or self-funded) plan, the costs of medical care are
a) Borne by the employer on a pay-as-you-go basis
b) Backed-up by stop-loss insurance against a catastrophic claim
c) Mandated by the Affordable Care Act for small businesses unable to obtain commercial
coverage
d) Created by a combination of employer and employee contributions
A
In choosing a setting for pt financial discussions, organizations should first and foremost
a) Have processes in place to document the discussions
b) Assess locations for convenience, professionalism, and comfort
c) Respect the pts privacy
d) Ensure all staff involved are properly trained and the pt financial education is included
in all discussions
C
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 pts account
c) Completing balance activities
d) Issuing receipts
D
Which option is a government-sponsored health care program that is financed through
taxesand general revenue funds
a) Medicaid
b) Medicare
c) Insurance exchange
d) Social security
B
It is important to calculate reserves to ensure
a) Stable financial operations and accurate financial reporting
b) Collateral for credit
c) Expense coverage in the event of a revenue short fall
d) Coverage of B/D write offs and charity care costs
A
Successful account resolution begins with
a) Educating pts on their estimated financial responsibility
b) Collecting all deductibles and copayments during the pre-service stage
c) Accurate documentation of services
d) Pt compliance with the course of treatment
B
An individual enrolled in Medicare who is dissatisfied with the government’s claim
determination is entitled to reconsideration of the decision. This type of appeal is known
as
a) A medicare determination appeal
b) A payment review
c) A medicare supplemental review
d) A beneficiary appeal
D
A portion of the accounts receivable inventory which has NOT qualified for billing
includes
a) Charitable pledges
b) Accounts assigned to a pre-collection agency
c) Accounts coded but held within the suspense period
d) Accounts created during pre-registration but not activated
A
Checks received through mail, cash received through mail, and lock box are all examples
of
a) Highly fraud prone processes
b) Payment methods in which the majority of fraud occurs
c) Payment methods being phased out for more secure payment method options
d) Control points for cash posting
D
Recognizing that health coverage is complicated and not all pts are able to navigate this
terrain, HFMA best practices specify that
a) A representative of the health plan be included in the pt financial responsibilities
discussion
b) The patient accounts staff have someone assigned to research coverage on behalf of
pts
c) Pts should be given the opportunity to request a pt advocate, family
member or other designee to help them In these discussions
d) Pt coverage education may need to be provided by the health plan
C
Once the price is estimated in the pre-service stage, a provider’s financial best practice is to
a) Allow the pt time to compare prices with other providers
b) Have another employee double check the price estimate
c) Lock-in the prices
d) Explain to the pt their financial responsibility and to determine the plan for payment
D
Charges as the most appropriate measurement of utilization enables
a) Accuracy of expense and cost capture
b) Managing of expense budgets
c) Effective HIM planning
d) Generation of timely and accurate billing
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) HMO
b) PPO
c) MSO
d) GPO
A
Charges are the basis for
a) Third party and regulatory review of resources used
b) Evaluating quality
c) Separation of fiscal responsibilities between the pt and the health plan
d) Demonstrating medical necessity
C
Chapter 13 Bankruptcy, debtor rehabilitation is a court proceeding
a) That reorganizes a debtor’s holdings and instructs creditors to look to the debtors’
future earnings for payment
b) That establishes a payment priority order to creditos’
c) That creates a clear court-supervised payment accountability plan going forward
d) That classifies the debtor as eligible for government financial assistance for housing
medical treatment and food as debts are paid
A
Pt financial communications best practices produce communications that are
a) Timely and remind pts of their financial responsibilities
b) Consistent, clear and transparent
c) Current and report the status of a pts claim
d) Timely, comprehensive and specifying next steps
B
Key performance indicators (KPIs) set standards for accounts receivables (A/R) and
a) Establish productivity targets
b) Provide a method of measuring the collection and control of A/R
c) Provide evidence of financial status
d) Make allowance for accurate revenue forecasting
B
When Recovery Audit Contractors (RAC) identify improper payments as over payments,
the
claims processing contractor must
a) Assume legal responsibility for repaying the overage amount
b) Make recovery of the overpayment the top processing priority
c) Send a demand letter to the provider to recover the over payment amount
d) Conduct an audit of all the effected providers claims within the past twelve months
C
A recurring/series registration is characterized by
a) The creation of one registration record for multiple days of service
b) The creation of multiple registrations for multiple services
c) The creation of one registration record per diagnosis per visits
d) The creation of multiple pt types for one date of service
A
It is important to have high registration quality standards because
a) Inaccurate or incomplete pt data will delay payment or cause denials
b) Incomplete registrations will trigger exclusion from Medicare participation
c) Inaccurate registration may cause discharge before full treatment is obtained
d) Incomplete registrations will raise satisfaction scores for the hospital
A
When recovery audit contractors (RAC) identify improper payments as over payments the
claims processing contractor must
a) Assume legal responsibility for repaying the overage amount
b) Make recovery of the overpayment the top processing priority
c) Send a demand letter to the provider to recover the over payment
amount
d) Conduct an audit of all the effected providers claims within the past 12 months
C
Internal controls addressing coding and reimbursement changes are put I place to guard
against
a) Underpayments
b) Denials
c) Compliance fraud by upcoding
d) Charge master error
C
The pt discharge process begins when
a) The physician writes the discharge orders
b) Clinical services are completed and pt accounts have all the info necessary to bill
c) The physician writes the discharge orders and the third-party payer sign-off on the
necessity of the services provided
d) Clinical services are completed, pt accounts can generated and accurate bill and there
is agreement o the handling of pt financial responsibilities
A
Most major health plans including medicare and Medicaid, offer
a) Toll free verification hot lines, staffed around the clock
b) Electronic and/or web portal verification
c) Pt “verification of benefits” cards
d) A grace period for obtaining verification within 72 hours of treatment
B
The physician who wrote the order for an inpatient service and is in charge of the pts
treatment during admission is
a) The pts personal physician
b) The primary care physician
c) The attending physician
d) The physician pt care director
C
An originating site is
a) The location where the pts bill is generated
b) The location of the pt at the time the service is provided
c) The site that generates reimbursement of a claim
d) The location of the medical treatment provider
B
HFMA best practices stipulate that a reasonable attempt should be made to have the
financial
responsibilities discussion
a) As early as possible, before a financial obligation is incurred
b) During the registration process
c) Before scheduling of services
d) No later than the evening of the day of admission
A
HFMA’s pt financial communications best practices specify that pts should be told about
the
types of services provided and
a) An explanation of why a specific service is not provided
b) The service providers that typically participate in the service, e.g.radiologists,
pathologists, etc.
c) A satisfaction survey regarding clinical service providers
d) The price of service to their covering health plan
B
Telemed seeks to improve a pt’s health by
a) Permitting 2-way real time interactive communication between the pt
and the clinical professional
b) Using high-compression fiber optics to transmit medical data
c) Providing relevant, on-demand consumer medical education
d) Providing physician access to the most current medical research
A
A large number of credit balances are not the result of overpayments but of
a) Posting errors in the pt accounting system
b) Incorrect claim submissions
c) Inadequate staff training
d) Banking transaction errors
A
Across all care settings, if a pt consents to a financial discussion during a medical
encounter
to expedite discharge, the HFMA best practice is to
a) Have a pt financial responsibilities kit ready for the pt containing all of the required
registration forms and instructions
b) Make sure that the attending staff can answer questions and assist in obtaining
required pt financial data
c) Support that choice, providing that the discussion does not interfere with pt care or
disrupt pt flow
d) Decline such request as finance discussions can disrupt pt care and pt flow
C
The office of inspector general (OIG) publishes a compliance work plan
a) Monthly
b) Quarterly
c) Semi-annually
d) Annually
D
What are collection agency fees based on?
A percentage of dollars collected
Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule?
Birthday
In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers?
Case rates
What customer service improvements might improve the patient accounts department?
Holding staff accountable for customer service during performance reviews
What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do?
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?
Bad debt adjustment
What is the initial hospice benefit?
Two 90-day periods and an unlimited number of subsequent periods
When does a hospital add ambulance charges to the Medicare inpatient claim?
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?
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
They are not being processed in a timely manner
What is an advantage of a preregistration program?
It reduces processing times at the time of service
What are the two statutory exclusions from hospice coverage?
Medically unnecessary services and custodial care
What core financial activities are resolved within patient access?
Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts
What statement applies to the scheduled outpatient?
The services do not involve an overnight stay
How is a mis-posted contractual allowance resolved?
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?
Observation
Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what?
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$?
When the patient is the insured
What are non-emergency patients who come for service without prior notification to the provider called?
Unscheduled patients
If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber’s spouse?
Neither enrolled not entitled to benefits
Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what?
Disclosure rules for consumer credit sales and consumer loans
What is a principal diagnosis?
Primary reason for the patient’s admission
Collecting patient liability dollars after service leads to what?
Lower accounts receivable levels
What is the daily out-of-pocket amount for each lifetime reserve day used?
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?
Inpatient care
What code indicates the disposition of the patient at the conclusion of service?
Patient discharge status code
What are hospitals required to do for Medicare credit balance accounts?
They result in lost reimbursement and additional cost to collect
When an undue delay of payment results from a dispute between the patient and the third party payer, who is responsible for payment?
Patient
Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include:
A valid CPT or HCPCS code
With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what?
Access their information and perform functions on-line
What date is required on all CMS 1500 claim forms?
onset date of current illness
What does scheduling allow provider staff to do
Review appropriateness of the service request
What code is used to report the provider’s most common semiprivate room rate?
Condition code
Regulations and requirements for coding accountable care organizations, which allows providers to begin creating these organizations, were finalized in:
2012
What is a primary responsibility of the Recover Audit Contractor?
To correctly identify proper payments for Medicare Part A & B claims
How must providers handle credit balances?
Comply with state statutes concerning reporting credit balance
Insurance verification results in what?
The accurate identification of the patient’s eligibility and benefits
What form is used to bill Medicare for rural health clinics?
CMS 1500
What activities are completed when a scheduled pre-registered patient arrives for service?
Registering the patient and directing the patient to the service area
In addition to being supported by information found in the patient’s chart, a CMS 1500 claim must be coded using what?
HCPCS (Healthcare Common Procedure Coding system)
What results from a denied claim?
The provider incurs rework and appeal costs
Why does the financial counselor need pricing for services?
To calculate the patient’s financial responsibility
What type of provider bills third-party payers using CMS 1500 form
Hospital-based mammography centers
How are disputes with nongovernmental payers resolved?
Appeal conditions specified in the individual payer’s contract
The important message from Medicare provides beneficiaries with information concerning what?
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?
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?
Submit interim bills to the Medicare program.
- MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens?
120 days passes, but the claim then be withdrawn from the liability carrier
What data are required to establish a new MPI entry?
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?
Determine the correct payer and notify the incorrect payer of the processing error
What do EMTALA regulations require on-call physicians to do?
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?
They must be balanced
What will cause a CMS 1500 claim to be rejected?
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?
The cost of the test
how are HCPCS codes and the appropriate modifiers used?
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?
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?
Patient arrival processing is expedited, reducing wait times and delays
What is a characteristic of a managed contracting methodology?
Prospectively set rates for inpatient and outpatient services
What do the MSP disability rules require?
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?
Blue Cross and blue Shield
What is true about screening a beneficiary for possible MSP situations?
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?
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?
Receive a fixed for specific procedures
What will comprehensive patient access processing accomplish?
Minimize the need for follow-up on insurance accounts
Through what document does a hospital establish compliance standards?
Code of conduct
How does utilization review staff use correct insurance information?
To obtain approval for inpatient days and coordinate services
When is it not appropriate to use observation status?
As a substitute for an inpatient admission
What is a serious consequence of misidentifying a patient in the MPI?
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?
Redirect the patient to the patient access department for registration
What process can be used to shorten claim turnaround time?
Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail
How are patient reminder calls used?
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?
Write off the account to the contractual adjustment account
According to the Department of Health and Human Services guidelines, what is NOT considered income?
Sale of property, house, or car
The situation where neither the patient nor spouse is employed is described to the patient using:
A condition code
What option is an alternative to valid long-term payment plans?
Bank loans
What is an advantage of using a collection agency to collect delinquent patient accounts?
Collection agencies collect accounts faster than hospital does
What statement DOES NOT apply to revenue codes?
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
catastrophic charity
What happens when a patient receives non-emergent services from and out-of-network provider?
Patient payment responsibility is higher
Every patient who is new to the healthcare provider must be offered what?
A printed copy of the provider’s privacy notice
How may a collection agency demonstrate its performance?
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?
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?
The UB-04 and the CMS 1500
Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information?
Obtain the required demographic and insurance information before services are rendered
what protocol was developed through the Patient Friendly Billing Project?
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?
Ask if the patient’s current services was accident related
What is a valid reason for a payer to delay a claim?
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
They must be combined with the inpatient bill and paid under the MS-DRG system
What do large adjustments require?
Manager-level approval
What items are valid identifiers to establish a patient’s identification?
Photo identification, date of birth, and social security number
What must a provider do to qualify an account as a Medicare bad debts?
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?
Site-of-service limitation
What is an example of an outcome of the Patient Friendly Billing Project?
Redesigned patient billing statements using patient-friendly language
What statement describes the APC (Ambulatory payment classification) system?
APC rates are calculated on a national basis and are wage-adjusted by geographic region
What is a benefit of insurance verification?
Pre-certification or pre-authorization requirements are confirmed
What is an effective tool to help staff collect payments at the time of service?
Develop scripts for the process of requesting payments
What is a benefit of electronic claims processing?
Providers can electronically view patient’s eligibility
What does Medicare Part D provide coverage for?
Prescription drugs
What are some core elements of a board-approved financial policy
Charity care, payment methods, and installment payment guidelines
What circumstance would result in an incorrect nightly room charge?
If the patient’s discharge, ordered for tomorrow, has not been charted
What is NOT a typical charge master problem that can result in a denial?
Does not include required modifiers
Access
An individual’s ability to obtain medical services on a timely and financially acceptable level
Administrative Services Only (ASO)
Usually contracted administrative services to a self-insured health plan
Case management
The process whereby all health-related components of a case are managed by a designated health professional. Intended to ensure continuity of healthcare accessibility and services
Claim
A demand by an insured person for the benefits provided by the group contract
Coordination of benefits (COB)
a typical insurance provision that determines the responsibility for primary payment when the patient is covered by more than one employer-sponsored health benefit program
Discounted fee-for-service
A reimbursement methodology whereby a provider agrees to provide service on a fee for service basis, but the fees are discounted by certain packages
Eligibility
Patient status regarding coverage for healthcare insurance benefits
First dollar coverage
A healthcare insurance policy that has no deductible and covers the first dollar of an insured’s expenses
Gatekeeping
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
an insurance company that provides for the delivery or payment of healthcare services
Indemnity insurance
negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations
Medically necessary
Healthcare services that are required to preserve or maintain a person’s health status in accordance with medical practice standards
Out-of-area benefits
healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO
Out-of-pocket payments
Cash payments made by the insured for services not covered by the health insurance plan
Pre-admission review
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
A restriction on payments for charges directly resulting from a pre-existing health conditions
Same-day admission
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
Large employers who assume direct responsibility or risk for paying employees’ healthcare without purchasing health insurance
Subrogation
Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient’s medical expenses
Subscriber
An employer, a union, or an association that contracts with an insurance company for the healthcare plan it offers to eligible employees
Sub-specialist
A healthcare professional who is recognized to have expertise in a specialty of medicine or surgery
Third-part administrator (TPA)
Provides services to employers or insurance companies for utilization review, claims payment and benefit design
Third-party reimbursement
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)
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
Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients
Charge
The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid
Cost
The definition of cost varies by party incurring the expense
Price
the total amount a provider expects to be paid by payers and patients for healthcare services
Care purchaser
Individual or entity that contributes to the purchase of healthcare services
Payer
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
An entity, organization, or individual that furnishes a healthcare service
Out of pocket payment
The portion of the total payment for medical services and treatment for which the patient is responsible, including copayments, coinsurance, and deductibles
Price transparency
In health care, 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
Value
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?
Human resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations
FERA
Fraud Enforcement and Recovery act
ESRD
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?
Mitigate potential fraud and abuse in the industry-specific key risk areas
What is important about an effective corporate compliance program?
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
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?
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.
TRUE
The OIG has issued compliance guidance/model compliance plans for all of the following entities:
hospices. physician practices. ambulance providers
Providers who are found to be in violation of CMS regulations are subject to:
Corporate integrity agreements
What MSP situation requires LGHP
Disability
Which of the following statements are true of HFMA’s Financial Communications Best Practices
The best practices were developed specifically to help patients understand the cost of services, their individual insurance benefits, and their responsibility for balances after insurance, if any.
The patient experience includes all of the following except:
The average number of positive mentions received by the health system or practice and the public comments refuting unfriendly posts on social media sites.
Corporate compliance programs play an important role in protecting the integrity of operations and ensuring compliance with federal and state requirements. The code of conduct is:
All of the above
Specific to Medicare fee-for-service patients, which of the following payers have always been liable for payment?
Public health service programs, Federal grant programs, veteran affairs programs, black lung program services and work-related injuries and accidents (worker’ compensation claims)
Provider policies and procedures should be in place to reduce the risk of ethics violations. Examples of ethics violations include:
All of the above
Providers are now being reimbursed with a focus on the value of the services provided, rather than volume, which requires collaboration among providers.
What is the intended outcome of collaborations made through an ACO delivery system for a population of patients?
To eliminate duplicate services, prevent medical errors and ensure appropriateness of care.
Historically, revenue cycle has delt with contractual adjustments, bad debt and charity deductions from gross revenue. Although deductions continue to exist, the definition of net revenue has been modified through the implementation of ASC 606. Developed by the Financial Accounting Standards Board (FASB), this change became effective in 2018.
What is the new terminology now employed in the calculation of net patient services revenues?
Explicit prices concessions and implicit price concessions
Key performance indicators set standards for A/R and provide a method for measuring the control and collection of A/R.
What are the two KPIs used to monitor performance related to the production and submission of claims to third party payers and patients (self-pay)?
Elapsed days from discharge to final bill and elapsed days from final bill to claim/bill submission.
Consents are signed as part of the post-services process.
True
**False
Patient service costs are calculated in the pre-service process for schedule patients
**True
False
The patient is scheduled and registered for service is a time-of-service activity
True
**False
The patient account is monitored for payment is a time-of-service activity
True
**False
Case management and discharge planning services are a post-service activty
True
**False
Sending the bill electronically to the health plan is a time-of-service activity
True
**False
What happens during the post-service stage?
**A. Final coding of all services, preparation and submission of claims, payment processing and balance billing and resolution.
B. Orders are entered, results are reported, charges are generated, and diagnostic and procedural coding is initiated.
C. The encounter record is generated, and the patient and guarantor information is obtained and/or updated as required.
D. The focus is on the patient and his/her financial care, in addition to the clinical care provided for the patient.
The following statements describe best practices established by the Medical Debt Task Force. Check the box next to the True statements
**Educate Patients
**Coordinate to avoid duplicate patient contacts
Exercise moderate judgement when communicating with providers about scheduled services
**Be consistent in key aspects of account resolution
Report to healthcare plans when the patient’s account is transferred to collection agency
**Follow best practices for communication
Which option is NOT a main HFMA Healthcare Dollars & Sense® revenue cycle initiative?
A. Patient Financial Communications
B. Price Transparency
C. Medical Account Resolution
**D. Process Compliance
What is the objective of the HCAHPS initiative?
**A. To provide a standardized method for evaluating patients’ perspective on hospital care.
B. To provide clear communication and good customer service, which will give the provider a competitive edge.
C. To conduct evaluations concerning patients’ perspective on hospital care.
D. To make certain that during registration key information is verified by means of a picture ID and an insurance card.
Which option is NOT a department that supports and collaborates with the revenue cycle?
A. Information Technology
B. Clinical Services
C. Finance
**D. Assisted Living Services
Which option is NOT a continuum of care provider?
A. Physician
**B. Health Plan Contracting
C. Hospice
D. Skilled Nursing Facility
Which of the following are essential elements of an effective compliance program?
**Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines
**Established compliance standards and procedures
Automatic dismissal of any employee excluded from participation in a federal healthcare program
**Designation of a compliance officer employed within the Billing Department
**Oversight of personnel by high-level personnel.
Annually, the OIG publishes a work plan of compliance issues and objectives that will be focused on throughout the following year. Identify which option is NOT a work plan task mentioned in this course.
A. Payments to Physicians for Co-Surgery Procedures
B. Denials and Appeals in Medicare Part D
C. Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute-Care Transfer Policies
**D. Standard Unique Employer Identifier
In order to promote the use of correct coding methods on a national basis and prevent payment errors due to improper coding, CMS developed what?
**A. The Correct Coding Initiative (CCI)
B. The Advance Beneficiary Notice of Noncoverage (ABN)
C. The Medicare Secondary Payer (MSP)
D. Modifiers
Indicate if the activity is described by the appropriate description of the violation involved:
True – A staff member receives cash in the mail and does not immediately report the case to the manager for special handling. This is an example of financial misconduct
False – A mother sees a charge on her hospital bill for a circumcision for a newborn girl. This is an example of falsifying medical records to boost reimbursement.
True – A patient access staff member takes several file folders and highlighters home for personal use. This is an example of theft of property.
False – A physician documents a fictitious epidural in a patient’s medical record in an effort to receive additional payment. This is an example of miscoding claims
True – Several unauthorized claims are sent to a health plan with the wrong procedure code. This is an example of overcharging.
What do business/organizational ethics represent?
**A. Principles and standards by which organizations operate
B. A healthcare provider’s practices and principles
C. An employee’s actions influenced by experiences and value system
D. The patient privacy standard within healthcare
What is the intended outcome of collaborations made through an ACO delivery system?
**A. To ensure appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients.
B. To create cost-containment provisions to reform the healthcare delivery system.
C. To reform the healthcare system into a system that rewards greater value, improves the quality of care and increases efficiency in the delivery of services.
D. To provide financial incentives to physicians for reporting quality data to CMS.
Which of these statements describes the new methodology for the determination of net patient service revenue:
A. Net patient service revenue is defined as the average payment amount for the payer but not recorded until the end of the month processing is completed.
B. Gross patient service revenue is recorded as net patient service revenue until such time as all payments are received.
**C. Net patient service revenue is defined as the total incurred charges, less the explicit price concession, less any applicable implicit price concession(s) as applied to the specific portfolio of accounts.
D. Net patient service revenue is gross revenue minus any contractual adjustments applicable to the account. Any additional adjustments are not recorded until the account reaches a zero balance.
E. Net patient service revenue is the sum of the balances of all charges and payments recorded in the accounting period.
What are KPIs?
A. Benchmarks which are used to compare Key Performance Indicators in an organization to an agreed upon average or expected standard within the same industry.
**B. Key performance indicators, which set standards for accounts receivable (A/R) and provide a method of measuring the collection and control of A/R.
C. Days in A/R is calculated based on the value of the total accounts receivable on a specific date.
D. A component that can divide the accounts receivable into 30, 60, 90, 120 days, and over 120 days categories, based on the date of service/discharge
While the highest level of differentiation among patients is scheduled patient vs unscheduled patient, a variety of patient types are routinely identified in both the acute and non-acute settings. Which patient types are typically considered acute care patient types?
Observation, newborn, Emergency (ED)
Accurate identification of the patient is the first step in the scheduling process. Identifiers used in various combination to achieve accurate patient identification include?
Full legal name, date of birth, sex and social security number
Pre-registration is defined as:
The collection of demographic information, insurance data, financial information, providing reminders, prep information, and identifying the potential need for financial assistance for scheduled patients.
Medicare has unique features not found in other health plan programs. It is government sponsored and financed through taxes and general revenue funds. Which of the following statements accurately describes the various Medicare benefits programs:
Medicare Part A provides benefits for inpatient hospital services, skilled nursing care and home health care; Medicare Part B covers outpatient and professional services, Medicare Part C or Medicare Advantage plans are managed care plans combining Part A and Part B Coverages; and Medicare Part D is the prescription drug coverage benefit.
Which of the following statements about Medicaid eligibility is not true?
Medicaid categories are restricted to children, pregnant women and elderly in nursing homes.
Examples of managed care plans include:
All of the above
Patient Financial Communications best practices include all of the following activities except:
Collecting payment or initiating the process to immediately remove the patient from the service schedule.
Which statement includes the required components of an accurate pricing determination?
Insurance coverage and benefits, service or test involved, diagnosis and procedure codes, total estimated charges, adjudication calculations based on the patient’s benefit package.
The value of a robust scheduling and pre-registration process includes all of the following except:
Identification of patients who are likely to be “no shows”.
Which patients are considered scheduled?
A. Observation Patients
B. Emergency Department Patients
**C. Recurring/Series Patients
D. Hospice Care
Name the guideline that Medicare established to determine which diagnoses, signs, or symptoms are payable.
A. Patient Identifiers
**B. Local Coverage Determinations
C. Advance Beneficiary Notice
D. Scheduling Instructions
What is the purpose of insurance verification?
A. To identify information that does not have to be collected from the patient.
**B. To ensure accuracy of the health plan information.
C. To effectively complete the MSP screening process.
D. To complete guarantor information if the guarantor is not the patient.
Which option is a federally-aided, state-operated program to provide health and long-term care coverage?
A. Medicare
**B. Medicaid
C. Self-Insured Plans
D. Liability Coverage
Which option is NOT a specific managed care requirement?
A. Referrals
B. Notification
**C. Preferred Provider Organization
D. Discharge Planning
What is the first component of a pricing determination?
A. Identify the service or test involved
**B. Verification of the patient’s insurance eligibility and benefits
C. Inform the patient that physician services are or are not included
D. Use a worksheet or other tool for guidance in determining an estimate
The correct sequential order of the financial counseling steps for an uninsured patient’s surgery case are:
Greet patient and give your name
Explain organization’s financial care approach and patient’s financial responsibility
Review patient’s health plan benefits and status
Review anticipated charges and patient’s anticipated liability
Ask patient to resolve liability by reviewing payment options
For uninsured, explain financial assistance options
What is the purpose of financial counseling?
A. To address the most appropriate ways to conduct financial interactions at every point
B. To train staff on how to request payment and conduct conversations
**C. To educate the patient on his/her health plan coverage and financial responsibility for healthcare services
D. To help the patient understand exactly how a contracted health plan will resolve their benefit package
EMTALA prohibits inquiries about health plan or liability payer information if the inquiry will delay examination or treatment. What other requirements apply to the Emergency Department registration work?
ALL of the above
Typical activities which much be performed when an unscheduled patient arrives for service include:
Identification of patient in the MPI or initiation of a new MPI record, insurance verification of eligibility and benefits, managed care screening, medical necessity screening, price estimation and financial counseling to achieve the appropriate account resolution.
Case managers are involved from admission with the discharge planning process. The purpose of discharge planning is:
To estimate how long the patient will be in the hospital, identify the expected outcome of the hospitalization and initiate any special requirements for services at or after the time of discharge.
The chargemaster is basically a list of services, procedures, room accommodations, supplies, drugs, tests, etc. typically associated with the billing for services rendered to patients. Challenges typically associated with the billing for services rendered to patients. Challenges typically associated with the chargemaster include:
Omission of charges, obsolete or invalid codes, and the omission of required modifiers.
Ultimately, the services provided in the healthcare system are reduced to standard codes. The primary types of coding systems currently used in healthcare are:
ICD-10-CM/ICD-10-PCS; CPT/HCPCS codes
There are four code sets that provide health plans with additional information as they process claims. Those code sets are:
Condition codes, occurrence codes, occurrence span codes and value codes
Each type of service has unique billing rules which come into play during the provision of service. For the skilled nursing facility, care is covered if which of the following factors are present:
The patient required skilled services on a daily basis and those services can only be provided on an inpatient basis in a SNF.
DRG’s are a system of classifying inpatients on the basis of diagnoses, procedures, and co-morbidities for purposes of payment to hospitals. Each DRG includes:
A relative weight which is multiplied by the established base payment rate to calculate the reimbursement for a specific DRG. For exceptionally costly cases over a set dollar amount, an outlier payment is added to the calculated payment.
PPO networks represent one form of discounting commonly used by commercial payers. The silent PPO represents:
A discounting scheme whereby health plans apply generic PPO rates to discount a provider’s claims, even though there is no contractual arrangement between the silent PPO and the provider.
The concept of timely filing of claims is important to providers, payers and patients. Thus, providers are required to comply with timely claim filing rules.
Which of the following statements are NOT true about timely filing limitations:
Payers will waive timely filing denials for claims filed over a year from date of service.
What does EMTALA require hospitals to do?
**A. To provide a medical screening examination and stabilizing treatment to every person presenting at an ED and requesting medical evaluation or treatment.
B. To initially triage patients, where a “quick” registration record is generated to specifically allow order entry.
C. To complete a standardized form signed by all patients that is used to inform the patient about the admission and conditions which must be agreed upon.
D. To confirm information that may be used to identify the patient in the provider’s MPI, which includes the patient’s full, legal name, SSN, and/or date of birth.
In what manner do case managers assist revenue cycle staff?
A. By reviewing a patient’s individual case and recommend treatment changes.
B. With monitoring the progression of high resource consumptive cases.
C. By estimating how long the patient will be in the hospital and what the expected outcome will be.
**D. Providing assistance with written appeals to health plans related to utilization and other care issues.
Why is it critical that a chargemaster is reviewed and updated regularly?
**A. To ensure it supports and represents the services provided within the organization.
B. To ensure the most appropriate measure of the utilization of resources.
C. So the CPT databases can have the most current and accurate information.
D. Because charge descriptions can vary greatly between providers.
What is the responsibility of HIM?
**A. To maintain all patient medical records
B. To make information available instantly and securely to authorized users
C. To denote the medical procedures performed by a healthcare provider on a patient
D. To substantiate health insurance claims filed by the patient, the physician, and the provider
What are claim edits?
A. Various data sources including Medicare and Medicaid bulletins and manuals, individual health plan manuals
B. A multi-stakeholder collaboration of more than 130 organizations — providers, health plans, vendors, and government agencies
**C. Rules developed to verify the accuracy and completeness of claims based on each health plan’s policies
D. The submission, receipt, and processing of automated claims, thereby eliminating mail time and reducing data entry time
Which statement is NOT a unique billing rule specific to providers?
A. Overall aggregate payments made to a hospice are subject to a “cap amount”, calculated by the MAC at the end of the hospice cap period.
B. With the exception of physician services, Medicare reimbursement for hospice care is made at one of four pre-determined rates for each day of hospice care.
C. When billing services on a UB-04/837-I, specific CPT codes are collapsed into a single revenue code (520 or 521).
**D. A patient may be balance billed for whatever amount the non-contracting physician charges above the health plan’s reimbursement amount.
Which of the following statements does not apply to billing during the COVID-19 public health emergency:
A. Hospitals may change a sub-acute unit into an acute care unit without advanced approval from CMS.
**B. Telemedicine claims are not payable if the patient conducts the telemedicine visit from home.
C. CMS developed the concept of hospitals without walls to increase ICU and med-surge inpatient capacity during the COVID-19 pandemic.
D. Cost sharing has been waived for testing for COVID-19 in the ED, physician office, urgent care center or other ambulatory location.
What is the sequential order for a Silent PPO scheme?
The patient’s claims is sent to the listed primary insurance carrier
The patient’s insurance company (a silent PPO) runs the healthcare provider’s tax ID number through a PPO discount database or provides a repricing company a copy of the claim
After a successful “hit”, the claim is “re-priced” based on the PPO discounts that were accessed.
After applying the discount, the silent PPO states on the EOB that the healthcare provider agreed to reduce your bill based on your contract with the PPO
The medical provider accepts the health plan’s statement on the EOB and writes the discount off-never knowing that the discount was invalid.
Which concept is NOT a contracted payment model?
**A. Stop-Loss Provision
B. Percentage Discount
C. Per Diem Payment
D. Capitation
Credit balances may be created by any of the following activities except:
Credits to pharmacy charges posted before the claim final bills
Which of the following statements represent common reasons for inpatient claim denials?
Failure to obtain a required pre-authorization; failure to complete a continued stay authorization and services provided which were not medically necessary.
A 68 year old patient, a Medicare beneficiary, was in a car accident. A medical insurance claim was filed with the auto insurance carrier. Six months later this claim remains unpaid. How can the provider pursue payment from Medicare?
The provider must first bill the auto insurer; however, after a period of 120 days, if the claim remains unpaid, the provider may cancel the liability claim and bill Medicare.
The difference between bad debt and financial assistance (charity) is:
Bad debt represents a refusal to pay; charity represents an inability to pay
In order to qualify for financial assistance, a patient or guarantor should:
Provide the following documents: prior year tax return, employment check stubs from the prior three months and bank statements for the prior three months.
To comply with the requirements of Section 501(r) for tax-exempt hospitals chartered as 510(c)3 providers, the hospital must complete which of the following activities:
A community needs assessmenets
The three types of bankruptcy as defined in the 1979 Bankruptcy Act are:
Chapter 7 – Straight Bankruptcy, Chapter 11- Debtor Reorganization and Chapter 13- Debtor Rehabilitation
Which of the following medical debt collection practices are recommended as part of HFMA’s Best Practices for medical account resolution:
Establish policies and ensure that they are followed
Organizations may opt to contract with or outsource to specific vendors for some or all components of revenue cycle processing. This practice has both advantages and disadvantages. Which of the following statements is NOT an advantage of utilizing an outsourcing vendor?
The need for legal review if the outside vendor’s staff represents themselves as employees of the healthcare facility.
Each hospital covered by the 501(r) regulations is required to develop a financial assistance policy. Which of the following elements is NOT a required element of the policy?
The notice that individuals eligible for financial assistance under this policy may be charged more that the amount generally billed (AGB) to insured patients.
Place the daily reconciliation process steps in the correct sequential order:
Obtain totals of all payments – cash, check, credit card, and debit card
Divide remittances into batches and obtain a second total of the electronic remittance advices by payment and contractual allowances
Endorse checks immediately. Prepare the bank deposit for all payments.
Separate cash payments and contractual adjustments into separate batches and use separate payments and adjustment codes.
Post unidentified payments to an unidentified cash account (deposit everything, do not hold unidentified payments)
Balance and post batches. Balance payments to the bank deposit. Balance the bank deposit to the general ledger.
Sue Smith came into the hospital. Her insurance provider sent an EFT directly into the hospital’s account at the bank. John, the hospital representative, receives an electronic Level 2 ERA. What should he do next?
**A. Manually match the ERA to the patient account.
B. Nothing unless there is an error.
What is EFT?
**A. The electronic transfer of funds from payer to payee through the banking system.
B. The establishment of internal audits by personnel outside the involved department.
C. A standardized healthcare claim payment/advice known as the 835 format.
D. A process that requires the separation of duties when processing patient payments.
Which statement is false regarding credit balances?
A. A small credit policy should be matched by a similar policy for small debit balances.
B. Tracking reports should be developed to identify internal charge credits versus external charge credits.
C. Hospital generated statements should be sent to patients regarding small credit balances.
**D. There are no CMS hospital compliance requirements regarding credit balances.
Which option is NOT a type of denial?
A. Technical
B. Clinical
C. Underpayment
**D. Contractual Adjustment
Which option is NOT a lien type?
A. Judicial
**B. Subrogation
C. Statutory
D. Agreement (Consensus)
Based on what you have just read, which activity is not considered when initiating self-pay follow-up and account resolution activities?
A. Poverty Guidelines
B. Financial Profile
C. Presumptive Financial Assistance Determination
**D. Patient Open Balance Billing
Which option is NOT a required component of a FAP?
A. Eligibility criteria
B. Application process
C. Application assistance
**D. Out-of-network providers
Which option is NOT a bankruptcy type governed by the 1979 Bankruptcy Act?
A. Straight bankruptcy
B. Debtor reorganization
**C. Creditor priority
D. Debtor rehabilitation
Which evaluation criteria demonstrates reputation expectations:
A. The agency’s Yelp score and consumer comments.
B. The amount of monies collected monthly.
**C. The employment of staff who have documented experience working in financial areas of health care.
D. The high turnover rate for entry level employees.
Agency fees are:
A. Paid by patients.
**B. The cost to the provider for collection agency monies offset by the return on baddebt accounts.
C. Only reported annually to the provider.
D. Waived for accounts aged greater than one year from date of service.
The correct way to handle the retention and payment of agency fees is:
A. The agency provides an annual settlement of monies received by the health care provider and the agency.
B. Compare estimated collection costs to actual costs incurred.
C. Validate bank deposits weekly as funds are received from the agency.
**D. Follow the contractual agreement between the agency and the provider as to how monies sent to the agency will be handled.
Patient relations include:
**A. The ability to sensitively deal with patients or individuals while managing collection efficiency.
B. Applying hard-core techniques to collect monies owed regardless of what the patient or individual states during the call.
C. Ignoring all patient complaint calls.
D. Referring all patient complaint calls to the healthcare provider.
Collection agency reports should be provided:
A. Whenever staff have the time to generate them.
B. Whenever an account is cancelled.
**C. In at least two formats regarding accounts assigned on a routine basis.
D. As needed to prove recovery rates.
Collection results are:
A. Always guaranteed by the collection agency.
**B. Accurately calculated to demonstrate the actual recovery percentage rate.
C. Calculated using agency’s private formula.
D. Never reported except during contract negotiations.
Which option is NOT a HFMA best practice?
A. Coordinate the resolution of bad debt accounts with a law firm
B. Establish policies and ensure that they are followed
NOT – C. Coordinate account resolution activities with business affiliates
D. Report back to credit bureaus when an account is resolved
True or False: The following statement represents an advantage of outsourcing:
Access to qualified staff
**True
False
True or False: The following statement represents an advantage of outsourcing:
Vendor absorbs some financial risk based on “efficiency” factor
**True
False
True or False: The following statement represents an advantage of outsourcing:
Impact on direct control of accounts receivable
True
**False
True or False: The following statement represents an advantage of outsourcing:
Capitalizes on the economies of scale
**True
False
True or False: The following statement represents an advantage of outsourcing:
Limits internal staffing requirements
**True
False
True or False: The following statement represents an advantage of outsourcing:
Impact on customer service
True
**False
True or False: The following statement represents an advantage of outsourcing:
Legal impact if vendor represents themselves as provider employees
True
**False
True or False: The following statement represents an advantage of outsourcing:
Ineffective vendor results in increased costs
True
**False
ABC Hospital has experienced a 16% increase in new patients over the past 6 months. The hospital is understaffed in its insurance claim and payment processing department and cannot handle this increase in work load. It is considering hiring an outsourcing vendor to assist. What are the steps that the hospital needs to take to establish and ensure a successful vendor relationship?
**A. Distribute a RFP to solicit vendor capabilities, evaluate vendor’s expertise to provide outsourcing services, visit vendor locations, perform vendor reference checks, talk with vendor clients, interview vendor employees to assess experience level.
B. Evaluate vendor’s expertise in providing outsourcing services, visit vendor locations, interview vendor employees to assess expertise level.
Which function within the revenue cycle is NOT a good candidate for outsourcing?
**A. Health Care Patient Services
B. Patient Accounting
C. Patient Access
D. Health Information Management
revenue cycle compliance questions and answers
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