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
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