Admin & Finance - Section 4: Provider Enrollment and Fee Schedule Flashcards
Fee schedules are kept in offices to determine ____ for services rendered.
Compensation
A list of charges for health care services
Fee schedule
Why do health care providers keep fee schedules in their offices?
To specify the amount of compensation they want for providing selected services
True or False:
The clinic can have multiple fee schedules.
False; the clinic should have one unique fee schedule
True or False:
Commercial, Medicare, Medicare Advantage, Medicaid, Medicaid MCO, and self-pay patients can be charged different amounts.
False; all commercial, Medicare, Medicare Advantage, Medicaid, Medicaid MCO, and self-pay patients should be charged the same amount.
True or False:
All commercial, Medicare, Medicare Advantage, Medicaid, Medicaid MCO, and self-pay patients should be charged the same amount.
True
Why can’t a clinic have different fee schedules for different types of patients?
Different fee schedules can be viewed as a form of discrimination
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.
True
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.
False; payers will have different payment rules, claim submission requirements, and service reporting rules, but all fees should be the same across payers.
What is considered to be lynch pin of the revenue cycle?
The fee schedule
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
1) Payer
2) Charging
3) Discounts
4) Revenue
5) Managing
The objective of setting fees is to set the fee high enough to ____ commercial payer reimbursement.
Maximize
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?
Private pay patients
What percent of the charge amount does coinsurance account for for RHC patients?
20%
True or False:
Provider-based RHCs cannot have a different fee schedule than the parent hospital.
False; provider-based RHCs may have a different fee schedule than the parent hospital
An agreement (written, verbal, or inferred from conduct) among competitors that raises, lowers, or stabilizes prices or competitive terms is known as ____
Price fixing
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.
False; the antitrust laws require that each company establish prices and other terms on its own, without agreeing with a competitor
For price fixing to occur, the agreement must be written
False; an agreement can be written, verbal, or inferred from conduct
Setting fees based on what other providers are charging is considered to be what?
Illegal price fixing
True or False:
You should survey other providers to see what their fees are when setting your own fee schedule.
False; do not survey other area providers when setting fees
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?
Incorrect
True or False:
Clinics should use their customary fees when converting from a fee-for-service clinic to an RHC.
True
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.
1
True or False:
A clinic should jack up their fees when they’re becoming an RHC
False; you don’t want to jack your fees up because you’re becoming an RHC
What is the main indicator of an artificially low fee schedule?
Commercial payer payments are 100% of the charge
If a large portion of payments are 100% of the charge, what is appropriate and necessary?
A fee schedule assessment
If a large portion of payments are 100% of the charge, why is a fee schedule assessment appropriate and necessary?
To ensure full reimbursement for the services rendered
True or False:
RHCs must follow a specific requirement when designating their fee schedule.
False; there is no specific requirement regarding what RHCs designate their fee schedule to be
True or False:
There is no specific requirement regarding what RHCs designate their fee schedule to be
True
When setting the fee schedule, it is required to use the ____ fees to set the fees.
Customary
What are the 2 common methods for setting fee schedules?
Medicare Allowable Multiplier and RBRVS
What does RBRVS stand for?
Resource-Based Relative Value Scale
Locality ____ can be used most often for “all other areas”.
99
What can locality 99 most often be used for?
“All other areas”
What is the zipcode to carrier locality file primary intended for?
To map zipcodes to CMS carriers/Medicare Administrative Contractors and Localities
True or False:
The zipcode to carrier locality files contains an urban, rural, or low density (qualified) area zip code indicator.
True
When setting the fee, what column should be looked at?
PAR Amount, stands for participating amount
When setting the fee, what does the # symbol indicate?
The reduced facility
True or False:
When setting the fee, you should use the entry that is denoted by the # symbol.
False; you should use the entry that is not denoted by #
When setting the fee, the Non-Par and Limiting Charge columns indicate what?
Non-participating providers. Can be disregarded.
When setting the fee, what is the lowest multiplier that our RHC consultant stated he would go?
150%
What is the multiplier range used when setting the fee schedule?
125%-200%
What is the most common and easiest method for setting fees?
Using the Medicare fee schedule
How do you use the Medicare allowable method to set fees?
Apply a multiplier to the Medicare allowable to create the clinic fee
The ____ system is being used by default when fees are based on a percentage of the Medicare allowable
RBRVS
What are the most common multipliers used?
150%, 175%, and 200%
The physician payment system used by the Centers for Medicare and Medicaid Services (CMS) and most other payers
Resource-Based Relative Value Scale (RBRVS)
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
Resource-Based Relative Value Scale (RBRVS)
RBRVS is based on the principle that payments for physician services should ____ within the resource costs for providing those services
Vary
RBRVS is intended to ____ and ____ the payment system while providing physicians an avenue to continuously improve it
Improve and stabilize
Within RBRVS, how are payments determined?
By the resource costs needed to provide them
Within RBRVS, each service is divided into what 3 components?
1) Physician work
2) Practice expense
3) Professional liability insurance (PLI)
Within RBRVS, how are payments calculated?
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
Within RBRVS, payments are calculated by multiplying what 2 things?
Combined costs of a service and a conversion factor (a monetary amount determined by CMS)
Within RBRVS, payments are calculated by adjusting for ____ differences in resource costs
Geographical
Within RBRVS, payments are calculated by adjusting for geographical difference in ____ costs
Resource
With RBRVS, a “____ ____” is set for each service based on the amount of physician work, work expense, and malpractice expense.
Relative value
With RBRVS, who publishes conversion factors for each CPT code?
CMS
The relative value, multiplied by the conversion factor, determines the payment for that service
RBRVS
True or False:
Fee schedules should be reviewed on a quarterly basis.
False; annual
Who publishes annual Medicare updates?
CMS
True or False:
It is best practice to make sure that fees are being adjusted along with Medicare allowables and the Medicare Economic Index
True
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.
5%-8%
True or False:
Fee schedules should be reviewed on an annual basis.
True
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
Medicare Economic Index (MEI)
The Medicare Economic Index is a measure of practice cost ____
Inflation
What does MEI stand for?
Medicare Economic Index
When was the Medicare Economic Index developed?
1975
The Medicare Economic Index is used to estimate ____ changes in physicians’ operating costs and earning levels
Annual
The Medicare Economic Index is used to estimate annual changes in physicians’ ____ costs and earning levels
Operating
The Medicare Economic Index is used to estimate annual changes in physicians’ operating costs and ____ levels
Earning
Suppliers use different ____ enrollment application forms to enroll or change their Medicare enrollment information
CMS
What is the use of CMS enrollment application forms dependent on?
Supplier type and enrollment scenario
Who is the Identity and Access System used by?
CMS
The I&A Management System is used by CMS to allow users to do what?
Access and control access
The I&A Management System is used by CMS to allow users to access and control access to what 4 systems?
PECOS, National Plan and Provider Enumeration System (NPPES), Electronic Health Record (EHR), and Merit-Based Incentive Payment System (MIPS)
The I&A Management System is used by CMS to allow ____ to the providers, organization, or sole owned practice.
Access
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
All
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
All
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
All
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
4 only
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
4 only
The National Provider Identifier (NPI) is a HIPAA ____ standard.
Administrative
A unique identification number for covered health care providers, created to improve the efficiency and effectiveness of electronic transmission health information
NPI
What does NPI stand for?
National Provider Identifier
An NPI is a ____ identification number for covered health care providers
Unique
The NPI was created for what purpose?
To improve the efficiency and effectiveness of the electronic transmission of health information
What must covered health care providers, all health plans, and health care clearinghouses use in their administrative and financial transactions?
NPI
What does PECOS stand for?
Provider Enrollment, Chain, and Ownership System
This online Medicare provider enrollment system allows you to enroll in Medicare, update enrollment information, and assign privileges to an organization
PECOS
What institutions should use Medicare Part A Enrollment: Institutional Providers?
Hospital, critical facility, skilled nursing facility, home health agency, hospice, or other similar institutions
What Medicare Part covers physicians, non-physician practitioners (NPPs)?
Part B
True or False:
RHCs are not on the list of Part B suppliers for Medicare
True
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
True
What is the name of the Medicare enrollment application for clinics/group practice and certain other providers?
855B
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
855B
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?
855B
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?
855B
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?
855B
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?
855B
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.
Medicare Part B: 855I
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?
855I
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?
855I
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?
855I
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?
855I
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?
855I
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?
855I
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?
855I
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.
Medicare Part B: 855R
Independent RHCs are assign a CMS Certification Number (CCN) in what ranges?
3800-3974, 8900-8999
Provider-based RHCs are an integral and subordinate part of which 3 types of facilities?
1) Hospitals
2) SNF
3) Home health agency
Provider-based hospitals are assigned a CCN in what ranges?
3400-3499, 3975-3999, or 8500-8899
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
True
How are non-RHC service in a provider based RHC billed?
Using the parent hospital’s CCN/EIN and the RHC as the service location
For provider based non-RHC services, does the RHC have to be added to the parent hospital CCN? If yes, how is it added?
Yes, through a Medicare 855A Change of Information (CHOI)
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
False; it can be
True or False:
Provider based attestations are mandatory
False; this process is voluntary but highly encouraged
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
True
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
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
True or False:
Provider based compliance is assumed when a provider based CCN is issued
False; Provider based compliance is not assumed when a provider based CCN is issued
What application is used to enroll in the RHC program with Medicare for institutional providers?
855A
True or False:
Every state has the same Medicaid provider enrollment requirements for RHCs and RHC providers
False; Each state has their own Medicaid provider enrollment requirements and processes for RHCs and RHC providers.
True or False:
Some states require separate, state licenses as RHCs
True
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
False; These licenses must usually be obtained before any other RHC enrollment is performed.
To be reimbursed by a Medicaid MCO as a RHC, you must be enrolled with each Medicaid MCO ____
Separately
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.
True
In the Medicaid MCO reimbursement process, the RHC submits a MCO payment report to the ____ Medicaid agency
State
In the Medicaid MCO reimbursement process, the state Medicaid agency will reconcile the MCO payment to the RHC ____ ____.
Encounter rate
True or False:
Most states have implemented some form of managed care organization (MCO) consolidation for Medicaid beneficiaries
True
There are typically ____ or more Medicaid MCOs which service state managed care plans.
Three
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.
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.
True or False:
Participation with state managed Medicaid plans is automatic.
False; Participation with state managed Medicaid plans is not automatic. Each RHC or RHC provider (depending on the plan) must be enrolled individually.
What are the 5 payer types?
Medicare and Medicaid Discounted fee-for-service Managed care Preferred provider organizations Capitation
What does “participation” mean in Medicare?
A provider agrees to always accept assignment of claims for all services you furnish to Medicare beneficiaries
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
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.
True or False:
RHC are participating providers with Medicare
True
True or False:
RHCs are required to offer a sliding fee scale
False; RHCs are not required to offer a sliding fee scale
Only sites designated as ____ ____ ____ by HRSA are required to offer income-based sliding fee scales and to see patients regardles of ability to pay
Loan repayment sites
True or False:
If you are designated as a loan repayment site, you are required to see patients regardless of their ability to pay
True
True or False:
If you are designated as a loan repayment site, you are required to offer income-based sliding fee scales
True
Discounts applied to the customary clinic fee schedule
Sliding fee scale
What 3 things is a sliding fee scale generally based on?
Income, family size, federal poverty guidelines
How often are the federal poverty guidelines updated?
Every 2 years
How are sliding fee scales best implemented?
Using the clinic fee and then applying a discount
True or False:
RHCs should have multiple fee schedules for different types of patients to keep from having to adjust rates individually
False; RHCs should have one fee schedule for all patients and then use the discount policy to adjust rates individually.
Most commercial payers are discounted ____ .
PPOs
A preferred provider network (PPO) is on where patients must see “____-____” providers
In-network
How do providers become in-network with commercial payers?
Providers must sign contracts and go through the enrollment process
True or False:
Commercial payers have their own allowable amounts for in-network or may stipulate payment based on the Medicare fee schedule
True
