Admin & Finance - Section 4: Provider Enrollment and Fee Schedule

Question 1

Fee schedules are kept in offices to determine ____ for services rendered.

Answer 1

Compensation

Question 2

A list of charges for health care services

Answer 2

Fee schedule

Question 3

Why do health care providers keep fee schedules in their offices?

Answer 3

To specify the amount of compensation they want for providing selected services

Question 4

True or False:

The clinic can have multiple fee schedules.

Answer 4

False; the clinic should have one unique fee schedule

Question 5

True or False:

Commercial, Medicare, Medicare Advantage, Medicaid, Medicaid MCO, and self-pay patients can be charged different amounts.

Answer 5

False; all commercial, Medicare, Medicare Advantage, Medicaid, Medicaid MCO, and self-pay patients should be charged the same amount.

Question 6

True or False:

All commercial, Medicare, Medicare Advantage, Medicaid, Medicaid MCO, and self-pay patients should be charged the same amount.

Answer 6

True

Question 7

Why can’t a clinic have different fee schedules for different types of patients?

Answer 7

Different fee schedules can be viewed as a form of discrimination

Question 8

True or False:

Payers will have different payment rules, claim submission requirements, and service reporting rules, but all fees should be the same across payers.

Answer 8

True

Question 9

True or False:

Even though payers will have different payment rules, claim submission requirements, and service reporting rules, fees do not have to be the same across payers.

Answer 9

False; payers will have different payment rules, claim submission requirements, and service reporting rules, but all fees should be the same across payers.

Question 10

What is considered to be lynch pin of the revenue cycle?

Answer 10

The fee schedule

Question 11

Fee schedules affect all financial aspects of an RHC. They are critical factors when:

1) Signing ____ agreements
2) ____ insurance companies
3) Offering charity care ____
4) Reporting ____ and adjustments
5) ____ the billing, coding, and documentation processes

Answer 11

1) Payer
2) Charging
3) Discounts
4) Revenue
5) Managing

Question 12

The objective of setting fees is to set the fee high enough to ____ commercial payer reimbursement.

Answer 12

Maximize

Question 13

The objective of setting fees is to set the fee high enough to maximize commercial payer reimbursement, but not so excessive that fees place an undue burden on what type of patients?

Answer 13

Private pay patients

Question 14

What percent of the charge amount does coinsurance account for for RHC patients?

Answer 14

20%

Question 15

True or False:

Provider-based RHCs cannot have a different fee schedule than the parent hospital.

Answer 15

False; provider-based RHCs may have a different fee schedule than the parent hospital

Question 16

An agreement (written, verbal, or inferred from conduct) among competitors that raises, lowers, or stabilizes prices or competitive terms is known as ____

Answer 16

Price fixing

Question 17

True or False:

Generally, antitrust laws required that companies work together to establish prices and other terms. Companies should seek to agree with their competitors on these items as well.

Answer 17

False; the antitrust laws require that each company establish prices and other terms on its own, without agreeing with a competitor

Question 18

For price fixing to occur, the agreement must be written

Answer 18

False; an agreement can be written, verbal, or inferred from conduct

Question 19

Setting fees based on what other providers are charging is considered to be what?

Answer 19

Illegal price fixing

Question 20

True or False:

You should survey other providers to see what their fees are when setting your own fee schedule.

Answer 20

False; do not survey other area providers when setting fees

Question 21

Many RHCs want to use the all-inclusive rate (AIR)/encounter rate as their Medicare charge amount. Is this correct or incorrect reporting for Medicare claims?

Answer 21

Incorrect

Question 22

True or False:

Clinics should use their customary fees when converting from a fee-for-service clinic to an RHC.

Answer 22

True

Question 23

Choose one:

1) RHCs should not match their clinic fees to their encounter rate.
2) RHCs should match their clinic fees to their encounter rate.

Answer 23

1

Question 24

True or False:

A clinic should jack up their fees when they’re becoming an RHC

Answer 24

False; you don’t want to jack your fees up because you’re becoming an RHC

Question 25

What is the main indicator of an artificially low fee schedule?

Answer 25

Commercial payer payments are 100% of the charge

Question 26

If a large portion of payments are 100% of the charge, what is appropriate and necessary?

Answer 26

A fee schedule assessment

Question 27

If a large portion of payments are 100% of the charge, why is a fee schedule assessment appropriate and necessary?

Answer 27

To ensure full reimbursement for the services rendered

Question 28

True or False:

RHCs must follow a specific requirement when designating their fee schedule.

Answer 28

False; there is no specific requirement regarding what RHCs designate their fee schedule to be

Question 29

True or False:

There is no specific requirement regarding what RHCs designate their fee schedule to be

Answer 29

True

Question 30

When setting the fee schedule, it is required to use the ____ fees to set the fees.

Answer 30

Customary

Question 31

What are the 2 common methods for setting fee schedules?

Answer 31

Medicare Allowable Multiplier and RBRVS

Question 32

What does RBRVS stand for?

Answer 32

Resource-Based Relative Value Scale

Question 33

Locality ____ can be used most often for “all other areas”.

Answer 33

99

Question 34

What can locality 99 most often be used for?

Answer 34

“All other areas”

Question 35

What is the zipcode to carrier locality file primary intended for?

Answer 35

To map zipcodes to CMS carriers/Medicare Administrative Contractors and Localities

Question 36

True or False:

The zipcode to carrier locality files contains an urban, rural, or low density (qualified) area zip code indicator.

Answer 36

True

Question 37

When setting the fee, what column should be looked at?

Answer 37

PAR Amount, stands for participating amount

Question 38

When setting the fee, what does the # symbol indicate?

Answer 38

The reduced facility

Question 39

True or False:

When setting the fee, you should use the entry that is denoted by the # symbol.

Answer 39

False; you should use the entry that is not denoted by #

Question 40

When setting the fee, the Non-Par and Limiting Charge columns indicate what?

Answer 40

Non-participating providers. Can be disregarded.

Question 41

When setting the fee, what is the lowest multiplier that our RHC consultant stated he would go?

Answer 41

150%

Question 42

What is the multiplier range used when setting the fee schedule?

Answer 42

125%-200%

Question 43

What is the most common and easiest method for setting fees?

Answer 43

Using the Medicare fee schedule

Question 44

How do you use the Medicare allowable method to set fees?

Answer 44

Apply a multiplier to the Medicare allowable to create the clinic fee

Question 45

The ____ system is being used by default when fees are based on a percentage of the Medicare allowable

Answer 45

RBRVS

Question 46

What are the most common multipliers used?

Answer 46

150%, 175%, and 200%

Question 47

The physician payment system used by the Centers for Medicare and Medicaid Services (CMS) and most other payers

Answer 47

Resource-Based Relative Value Scale (RBRVS)

Question 48

Based on the principle that payments for physician services should vary within the resource costs for providing those services and is intended to improve and stabilize the payment system while providing physicians an avenue to continuously improve it

Answer 48

Resource-Based Relative Value Scale (RBRVS)

Question 49

RBRVS is based on the principle that payments for physician services should ____ within the resource costs for providing those services

Answer 49

Vary

Question 50

RBRVS is intended to ____ and ____ the payment system while providing physicians an avenue to continuously improve it

Answer 50

Improve and stabilize

Question 51

Within RBRVS, how are payments determined?

Answer 51

By the resource costs needed to provide them

Question 52

Within RBRVS, each service is divided into what 3 components?

Answer 52

1) Physician work
2) Practice expense
3) Professional liability insurance (PLI)

Question 53

Within RBRVS, how are payments calculated?

Answer 53

By multiplying the combined costs of a service with a conversion factor (a monetary amount determined by CMS) and adjusting for geographical differences in resource costs

Question 54

Within RBRVS, payments are calculated by multiplying what 2 things?

Answer 54

Combined costs of a service and a conversion factor (a monetary amount determined by CMS)

Question 55

Within RBRVS, payments are calculated by adjusting for ____ differences in resource costs

Answer 55

Geographical

Question 56

Within RBRVS, payments are calculated by adjusting for geographical difference in ____ costs

Answer 56

Resource

Question 57

With RBRVS, a “____ ____” is set for each service based on the amount of physician work, work expense, and malpractice expense.

Answer 57

Relative value

Question 58

With RBRVS, who publishes conversion factors for each CPT code?

Answer 58

CMS

Question 59

The relative value, multiplied by the conversion factor, determines the payment for that service

Answer 59

RBRVS

Question 60

True or False:

Fee schedules should be reviewed on a quarterly basis.

Answer 60

False; annual

Question 61

Who publishes annual Medicare updates?

Answer 61

CMS

Question 62

True or False:

It is best practice to make sure that fees are being adjusted along with Medicare allowables and the Medicare Economic Index

Answer 62

True

Question 63

If you haven’t maintained your fee schedule, a suggested increase of ____% - ____% is suggested for each year until you get where you want to be.

Answer 63

5%-8%

Question 64

True or False:

Fee schedules should be reviewed on an annual basis.

Answer 64

True

Question 65

A measure of practice cost inflation that was developed in 1975 as a way to estimate annual changes in physicians’ operating costs and earning levels

Answer 65

Medicare Economic Index (MEI)

Question 66

The Medicare Economic Index is a measure of practice cost ____

Answer 66

Inflation

Question 67

What does MEI stand for?

Answer 67

Medicare Economic Index

Question 68

When was the Medicare Economic Index developed?

Answer 68

1975

Question 69

The Medicare Economic Index is used to estimate ____ changes in physicians’ operating costs and earning levels

Answer 69

Annual

Question 70

The Medicare Economic Index is used to estimate annual changes in physicians’ ____ costs and earning levels

Answer 70

Operating

Question 71

The Medicare Economic Index is used to estimate annual changes in physicians’ operating costs and ____ levels

Answer 71

Earning

Question 72

Suppliers use different ____ enrollment application forms to enroll or change their Medicare enrollment information

Answer 72

CMS

Question 73

What is the use of CMS enrollment application forms dependent on?

Answer 73

Supplier type and enrollment scenario

Question 74

Who is the Identity and Access System used by?

Answer 74

CMS

Question 75

The I&A Management System is used by CMS to allow users to do what?

Answer 75

Access and control access

Question 76

The I&A Management System is used by CMS to allow users to access and control access to what 4 systems?

Answer 76

PECOS, National Plan and Provider Enumeration System (NPPES), Electronic Health Record (EHR), and Merit-Based Incentive Payment System (MIPS)

Question 77

The I&A Management System is used by CMS to allow ____ to the providers, organization, or sole owned practice.

Answer 77

Access

Question 78

Within I&A, an Individual Provider can do which of the following:

1) Represent an organization
2) Manage staff
3) Approve/manage connections
4) Act on behalf of a provider in CMS systems

Answer 78

All

Question 79

Within I&A, an Authorized Official can do which of the following:

1) Represent an organization
2) Manage staff
3) Approve/manage connections
4) Act on behalf of a provider in CMS systems

Answer 79

All

Question 80

Within I&A, an Access Manager can do which of the following:

1) Represent an organization
2) Manage staff
3) Approve/manage connections
4) Act on behalf of a provider in CMS systems

Answer 80

All

Question 81

Within I&A, a Staff End User can do which of the following:

1) Represent an organization
2) Manage staff
3) Approve/manage connections
4) Act on behalf of a provider in CMS systems

Answer 81

4 only

Question 82

Within I&A, a Surrogate can do which of the following:

1) Represent an organization
2) Manage staff
3) Approve/manage connections
4) Act on behalf of a provider in CMS systems

Answer 82

4 only

Question 83

The National Provider Identifier (NPI) is a HIPAA ____ standard.

Answer 83

Administrative

Question 84

A unique identification number for covered health care providers, created to improve the efficiency and effectiveness of electronic transmission health information

Answer 84

NPI

Question 85

What does NPI stand for?

Answer 85

National Provider Identifier

Question 86

An NPI is a ____ identification number for covered health care providers

Answer 86

Unique

Question 87

The NPI was created for what purpose?

Answer 87

To improve the efficiency and effectiveness of the electronic transmission of health information

Question 88

What must covered health care providers, all health plans, and health care clearinghouses use in their administrative and financial transactions?

Answer 88

NPI

Question 89

What does PECOS stand for?

Answer 89

Provider Enrollment, Chain, and Ownership System

Question 90

This online Medicare provider enrollment system allows you to enroll in Medicare, update enrollment information, and assign privileges to an organization

Answer 90

PECOS

Question 91

What institutions should use Medicare Part A Enrollment: Institutional Providers?

Answer 91

Hospital, critical facility, skilled nursing facility, home health agency, hospice, or other similar institutions

Question 92

What Medicare Part covers physicians, non-physician practitioners (NPPs)?

Answer 92

Part B

Question 93

True or False:

RHCs are not on the list of Part B suppliers for Medicare

Answer 93

True

Question 94

True or False:

Physicians, non-physician providers, and other Part B suppliers must enroll in the Medicare Program to get paid for the covered services they furnish to Medicare beneficiaries

Answer 94

True

Question 95

What is the name of the Medicare enrollment application for clinics/group practice and certain other providers?

Answer 95

855B

Question 96

This application is used by group practices and other organizational suppliers, except DMEPOS suppliers, to initiate the Medicare enrollment process or to change their Medicare enrollment information

Answer 96

855B

Question 97

If you are an organization/group that plans to bill Medicare and you are a hospital or other medical practice that may bill for Medicare Part A service but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B should use which Medicare enrollment form?

Answer 97

855B

Question 98

If you are an organization/group that plans to bill Medicare and you are a medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers) should use which Medicare enrollment form?

Answer 98

855B

Question 99

If you are an organization/group that plans to bill Medicare and you are currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor) should use which Medicare enrollment form?

Answer 99

855B

Question 100

If you are an organization/group that plans to bill Medicare and you are currently enrolled in Medicare and need to make changes to your enrollment data (e.g., you have added or changed a practice location), you should which Medicare enrollment form?

Answer 100

855B

Question 101

All physicians, as well as all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act, must complete this application to enroll in the Medicare program and receive a Medicare billing number.

Answer 101

Medicare Part B: 855I

Question 102

If you are an organization/group that plans to bill Medicare and you are currently enrolled in Medicare to order and certify and want to enroll as an individual practitioner to submit claims for services rendered, you should complete which Medicare form?

Answer 102

855I

Question 103

If you are an organization/group that plans to bill Medicare and you are an An individual practitioner or eligible professional who has formed a professional corporation, professional association, limited liability company, etc., of which you are the sole owner, you should complete which Medicare form?

Answer 103

855I

Question 104

If you are an organization/group that plans to bill Medicare and you are currently enrolled in Medicare and you received notice to revalidate your enrollment, you should use which Medicare form?

Answer 104

855I

Question 105

If you are an organization/group that plans to bill Medicare and you are previously enolled in Medicare and you need to reactivate your Medicare billing number to resume billing, you should use which Medicare form?

Answer 105

855I

Question 106

If you are an organization/group that plans to bill for Medicare and you are are currently enrolled in Medicare and need to enroll in another Medicare Administrative Contractor’s juridisdiction (e.g., you have opened a practice location in a geopgraphic territory serviced by another MAC), you should use which Medicare form?

Answer 106

855I

Question 107

If you are an organization/group that plans to bill Medicare and you are currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you have added or changed a practice location), you should use which Medicare form?

Answer 107

855I

Question 108

If you are an organization/group that plans to bill Medicare and you are voluntarily terminating your Medicare enrollment, you should use which Medicare form?

Answer 108

855I

Question 109

Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments for some or all of the services you render to Medicare beneficiaries, or are terminating a currently established reassignment of benefits.

Answer 109

Medicare Part B: 855R

Question 110

Independent RHCs are assign a CMS Certification Number (CCN) in what ranges?

Answer 110

3800-3974, 8900-8999

Question 111

Provider-based RHCs are an integral and subordinate part of which 3 types of facilities?

Answer 111

1) Hospitals
2) SNF
3) Home health agency

Question 112

Provider-based hospitals are assigned a CCN in what ranges?

Answer 112

3400-3499, 3975-3999, or 8500-8899

Question 113

True or False:

A provider based CCN is not an indiciation that the RHC has a provider based determination for purposes of an exception to the payment limit

Answer 113

True

Question 114

How are non-RHC service in a provider based RHC billed?

Answer 114

Using the parent hospital’s CCN/EIN and the RHC as the service location

Question 115

For provider based non-RHC services, does the RHC have to be added to the parent hospital CCN? If yes, how is it added?

Answer 115

Yes, through a Medicare 855A Change of Information (CHOI)

Question 116

True or False:

For provider based non-RHC services, the NPI used on the 855A cannot be the RHC NPI or alternate identifier already in use by the entity

Answer 116

False; it can be

Question 117

True or False:

Provider based attestations are mandatory

Answer 117

False; this process is voluntary but highly encouraged

Question 118

True or False:

Though not hospital departments, according to 42 eCFR413.65 (a)(2), RHCs must meet all financial, administrative, and operational integration and non-discriminative requirements as all hospital departments

Answer 118

True

Question 119

True or False:

Since a provider based RHC is not considered a hospital department, it does not need to meet all financial, admin, and operational integration and non-discriminative requirements as all hospital departments

Answer 119

False; Though not hospital departments, according to 42 eCFR413.65 (a)(2), RHCs must meet all financial, administrative, and operational integration and non-discriminative requirements as all hospital departments

Question 120

True or False:

Provider based compliance is assumed when a provider based CCN is issued

Answer 120

False; Provider based compliance is not assumed when a provider based CCN is issued

Question 121

What application is used to enroll in the RHC program with Medicare for institutional providers?

Answer 121

855A

Question 122

True or False:

Every state has the same Medicaid provider enrollment requirements for RHCs and RHC providers

Answer 122

False; Each state has their own Medicaid provider enrollment requirements and processes for RHCs and RHC providers.

Question 123

True or False:

Some states require separate, state licenses as RHCs

Answer 123

True

Question 124

True or False:

In states that require separate, state licenses as RHCs, the license doesn’t need to be obtained before any RHC enrollment is performed

Answer 124

False; These licenses must usually be obtained before any other RHC enrollment is performed.

Question 125

To be reimbursed by a Medicaid MCO as a RHC, you must be enrolled with each Medicaid MCO ____

Answer 125

Separately

Question 126

True or False:

If a provider is not enrolled with each Medicaid MCO, they cannot receive money from the Medicaid MCO. This means that the clinic also will not receive any money.

Answer 126

True

Question 127

In the Medicaid MCO reimbursement process, the RHC submits a MCO payment report to the ____ Medicaid agency

Answer 127

State

Question 128

In the Medicaid MCO reimbursement process, the state Medicaid agency will reconcile the MCO payment to the RHC ____ ____.

Answer 128

Encounter rate

Question 129

True or False:

Most states have implemented some form of managed care organization (MCO) consolidation for Medicaid beneficiaries

Answer 129

True

Question 130

There are typically ____ or more Medicaid MCOs which service state managed care plans.

Answer 130

Three

Question 131

True or False:

There are typically 3 or more MCOs which service state managed care plans. Each of these plans will have the same enrollment requirements and processes that are regulated by the state.

Answer 131

False; There are typically three or more MCOs which service state managed care plans. Each of these plans will have their own enrollment requirements and processes that are regulated by the state.

Question 132

True or False:

Participation with state managed Medicaid plans is automatic.

Answer 132

False; Participation with state managed Medicaid plans is not automatic. Each RHC or RHC provider (depending on the plan) must be enrolled individually.

Question 133

What are the 5 payer types?

Answer 133

Medicare and Medicaid
Discounted fee-for-service
Managed care
Preferred provider organizations
Capitation

Question 134

What does “participation” mean in Medicare?

Answer 134

A provider agrees to always accept assignment of claims for all services you furnish to Medicare beneficiaries

Question 135

True or False:

By agreeing to always accept assignment of claims for all services your furnish to Medicare beneficiaries, you agree to always accept Medicare-allowed payments in full but you can collect more than the Medicare deductible and coinsurance or copayment from the beneficiary if the Medicare payment didn’t cover the full charge

Answer 135

False; By agreeing to always accept assignment, you agree to always accept Medicare Medicare-allowed amounts as payment in full and not to collect more than the Medicare deductible and coinsurance or copayment from the beneficiary.

Question 136

True or False:

RHC are participating providers with Medicare

Answer 136

True

Question 137

True or False:

RHCs are required to offer a sliding fee scale

Answer 137

False; RHCs are not required to offer a sliding fee scale

Question 138

Only sites designated as ____ ____ ____ by HRSA are required to offer income-based sliding fee scales and to see patients regardles of ability to pay

Answer 138

Loan repayment sites

Question 139

True or False:

If you are designated as a loan repayment site, you are required to see patients regardless of their ability to pay

Answer 139

True

Question 140

True or False:

If you are designated as a loan repayment site, you are required to offer income-based sliding fee scales

Answer 140

True

Question 141

Discounts applied to the customary clinic fee schedule

Answer 141

Sliding fee scale

Question 142

What 3 things is a sliding fee scale generally based on?

Answer 142

Income, family size, federal poverty guidelines

Question 143

How often are the federal poverty guidelines updated?

Answer 143

Every 2 years

Question 144

How are sliding fee scales best implemented?

Answer 144

Using the clinic fee and then applying a discount

Question 145

True or False:

RHCs should have multiple fee schedules for different types of patients to keep from having to adjust rates individually

Answer 145

False; RHCs should have one fee schedule for all patients and then use the discount policy to adjust rates individually.

Question 146

Most commercial payers are discounted ____ .

Answer 146

PPOs

Question 147

A preferred provider network (PPO) is on where patients must see “____-____” providers

Answer 147

In-network

Question 148

How do providers become in-network with commercial payers?

Answer 148

Providers must sign contracts and go through the enrollment process

Question 149

True or False:

Commercial payers have their own allowable amounts for in-network or may stipulate payment based on the Medicare fee schedule

Answer 149

True