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CRHCP Course & Test > Billing & Coding - Section 4: Revenue Cycle Basics > Flashcards

Billing & Coding - Section 4: Revenue Cycle Basics Flashcards

1
Q

All of the administrative and clinical processes which represent the “life” of a patient account from its creation until payment resolution for an encounter or a series of encounters

A

Revenue cycle

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2
Q

The revenue cycle is all of ____ and ____ processes which represent the “life” of a patient account from its creation until payment resolution for an encounter or a series of encounters

A

Administrative and clinic

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3
Q

The revenue cycle is all of the administrative and clinical processes which represent the “life” of a patient account from its ____ until payment ____ for an encounter or a series of encounters

A

Creation

Resolution

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4
Q

The inter-related functions of the revenue cycle, when executed efficiently, result in ____ ____ in the shortest amount of time (A/R Days)

A

Maximum reimbursement

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5
Q

A weakness in any of the individual processes of the revenue cycle can directly affect the overall ____

A

Performance

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6
Q

We tend to think of revenue cycle management as an after-the-fact/back-end function, when, in face, most of our opportunities for optimizing revenue cycle performance and maximizing reimbursement are found ____ in the revenue cycle

A

Early

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7
Q

Where in the revenue are most opportunities found for optimizing revenue cycle performance and maximizing reimbursement?

A

Early in the revenue cycle

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8
Q

True or False:

The revenue cycle start before the patient even walks in the door.

A

True

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9
Q

Insurance payments, patient payments, third-party accounts, statements, and bad debts are found in which part of the revenue cycle?

A

Payment

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10
Q

Engagement, scheduling, registration, demographics, and data collection are found in which part of the revenue cycle?

A

Patient access

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11
Q

Medical necessity, authorizations, charge capture, documentation, and coding are found in which part of the revenue cycle?

A

Services provided

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12
Q

Contracting, provider enrollment, billing, adjudication, denial and rejections are found in which part of the revenue cycle?

A

Claims process

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13
Q

Where does the revenue cycle start?

A

Patient access

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14
Q

Advertising, marketing, PR, anything that gives the patient access to our clinic describes what part of the revenue cycle?

A

Patient access

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15
Q

Errors created at registration:

Inaccurate or out-of-date ____ information

A

Demographic

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16
Q

Errors created at registration:

Patient registered under ____ ____ than on insurance card

A

Different name

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17
Q

Errors created at registration:

Relationship of ____ to ____ error

A

Patient to policyholder

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18
Q

Errors created at registration:

Failure to update ____ or ____ information

A

Insurance or personal

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19
Q

True or False:

In the registration process, it is okay to just ask if all of their information is the same

A

False; don’t just ask this

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20
Q

Errors created at registration:

____ information incorrect or incomplete

A

Policyholder

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21
Q

Errors created at registration:

Date of birth (DOB) ____

A

Missing

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22
Q

Errors created at registration:

Medical identity ____ issues (drivers license, photo on file)

A

Fraud

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23
Q

Errors created at registration

____ ____ ____ Questionnaire
*Our responsibility to ask these questions as a Medicare provider

A

Medicare Secondary Payer

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24
Q

Errors created at registration:

Workers comp/liability or TPL visit. Why is this an error?

A

Need to ensure patient is not at visit for something that was the fault of someone else because that could mean that another insurance is primary and Medicare is secondary

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25
Q

Why is it important to let the front desk staff know how key their job is in the revenue cycle?

A

Because most front desk staff do not understand that when they register a patient, they are creating the majority of the data fields for the claim that will be submitted to the payer

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26
Q

Upfront/POS collections:

Make sure your staff is knowledgeable about how different health plans are ____

A

Structured

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27
Q

Upfront/POS collections:

Understand ____-____ plans and off-setting HSA and MSAs

A

High-deductible

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28
Q

Upfront/POS collections:

Have a financial counselor or supervisor available to discuss ____ ____. Why should you have this?

A

Payment options; protect your patient access staff from confrontation

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29
Q

Upfront/POS collections:

Verify ____ and ____ in advance. Use system tools to reduce on-phone time or bottlenecks.

A

Deductibles and co-insurance

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30
Q

Upfront/POS collections:

Train staff to be casual but direct about the patient’s anticipated ____ ____ of the service

A

Cost share

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31
Q

Upfront/POS collections:

Good customer service does not mean what?

A

We are too nice to take care of business

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32
Q

What is a good way to relate to your patients that they may have a cost share in their services?

A

You know when you go to Walmart that you will be expected to pay for the milk and bread in your hand before you walk out of the store

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33
Q

Errors occurring when services are provided or before:

Medical ____ not met

A

Necessity

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34
Q

Errors occurring when services are provided or before:

Service not provided at the required ____

A

Frequency

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35
Q

Errors occurring when services are provided or before:

____ coverage determinations

A

National

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36
Q

Errors occurring when services are provided or before:

Pre-____ for services/procedures

A

Authorization

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37
Q

Errors occurring when services are provided or before:

____ required?

A

Referral

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38
Q

Errors occurring when services are provided or before:

____ ____ Notice not issued

A

Advance Beneficiary

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39
Q

Errors occurring when services are provided or before:

Non-____ services are performend

A

Covered

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40
Q

Errors occurring when services are provided or before:

____ complaints

A

Doorknob

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41
Q

Errors occurring when services are provided or before:

Not all charges ____

A

Captured

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42
Q

Errors occurring when services are provided or before:

Not all services ____

A

Documented

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43
Q

Maximize provision of services:

____ administrative and clinical workflows

A

Efficient

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44
Q

Maximize provision of services:

Orders and ordering ____

A

Protocols

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45
Q

Maximize provision of services:

Minimize ____ processes

A

Manual

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46
Q

Maximize provision of services:

Have ____ and ____ in place to ensure charge capture and documentation

A

Checks and balances

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47
Q

Maximize provision of services:

____ your PM and EHR/EMR systems

A

Maximize

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48
Q

Maximize provision of services:

Don’t be afraid to re-engineer ____

A

Processes

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49
Q

Maximize provision of services:

Targeted ____ and ____ training on use of EHR

A

Provider and staff

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50
Q

Maximize provision of services:

Internal billing and coding ____

A

Reviews

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51
Q

If you discover an issue in charge capture, don’t be afraid to do what?

A

Re-engineer the process

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52
Q

How can you get around inefficiencies and redundacies?

A

By having a well-designed EHR and ensuring your staff is trained on it

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53
Q

Charge capture errors:

____ inefficiences

A

Workflow

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54
Q

Charge capture errors:

Poorly ____ templates or forms

A

Designed

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55
Q

Charge capture errors:

____ notes

A

Illegible

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56
Q

Charge capture notes:

System ____ and security matrix problems

A

Limitations

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57
Q

Charge capture errors:

Visits not ____/no ____ reconciliation process

A

Reconciled, daily

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58
Q

Charge capture errors:

Missed ____ (labs, drugs, or added services?

A

Charges

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59
Q

Charge capture errors:

____ tickets/unsigned records

A

Open

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60
Q

Charge capture errors:

Charges for services not ____

A

Performed

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61
Q

Charge capture errors:

Number of units reported not based on ____ description

A

HCPCS

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62
Q

Number of units reported not based on HCPCS is common with ____ code drugs

A

J

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63
Q

Charge capture errors:

NDC information ____

A

Missing

64
Q

Charge capture errors:

____-based services

A

Time

65
Q

Charge capture errors:

____ schedule and pricing methodology problems

A

Fee

66
Q

Common fee schedule errors:

Invalid, obsolete, or missing ____

A

Codes

67
Q

Common fee schedule errors:

Codes not updated ____

A

Regularly

68
Q

Common fee schedule errors:

New service not ____

A

Added

69
Q

Common fee schedule errors:

____ code descriptions/naming coventions

A

Inconsistent

70
Q

Common fee schedule errors:

Inconsistent fee setting methodologies -
Price not set the ____ ____
Prices not ____
Price ____ Medicare PFS

A

Same way
Updated
Below

71
Q

Common fee schedule errors:

Insufficient ____ of clinical or office staff

A

Training

72
Q

Common fee schedule errors:

No periodic review or ____

A

Analysis

73
Q

Common fee schedule errors:

____ not set up to drop correctly

A

Charges

74
Q

Codes change at least once each ____ but could be as often as quarterly

A

Year

75
Q

Codes changes at least once each year but could be as often as ____

A

Quarterly

76
Q

Documentation errors:

____ performed by not documented/captured

A

Services

77
Q

Documentation errors:

____ ____ not addressed, or diagnosis inconsistent with chief complaint

A

Chief complaint

78
Q

Documentation errors:

Documentation does not support ____ ____

A

Medical necessity

79
Q

Documentation errors:

Discrepancies in the ____

A

Record

80
Q

Documentation errors:

____ results not on chart or reviewed

A

Lab

81
Q

Documentation errors:

Not all pertinent ____ documented

A

Diagnoses

82
Q

Documentation errors:

Poorly designed or written ____/templates

A

Notes

83
Q

Documentation errors:

Inadequate ____ mastery

A

EHR

84
Q

Documentation errors:

Incomplete or delinquent ____

A

Records

85
Q

Errors in claim processing:

____ not set up correctly in your systems

A

Payers

86
Q

Errors in claim processing:

Providers not set up correctly in your ____

A

System

87
Q

Errors in claim processing:

Incomplete credentialing or provider ____

A

Enrollment

88
Q

Errors in claim processing:

NUBC ____ not followed

A

Guidelines

89
Q

Errors in claim processing:

Missing condition codes or ____

A

Modifiers

90
Q

Errors in claim processing:

Bypassing or overriding CCI ____

A

Edits

91
Q

Errors in claim processing:

____, software problems, EDI issues

A

Clearinghouse

92
Q

Errors in claim processing:

Submitting ____ claims

A

Duplicate

93
Q

Errors in claim processing:

Missing or incomplete patient ____

A

Information

94
Q

Errors in claim processing:

Claim submitted to wrong ____

A

Payer

95
Q

Errors in claims processing:

Use of non-specified ____

A

Codes

96
Q

Errors in claims processing:

Conflicts with ____’s business rules or billing guidelines

A

Payer’s

97
Q

Where is the first place to look if you’re having trouble getting claims out the door?

A

How the system is set up

98
Q

How can the front desk contribute to claims being submitted to the wrong payer?

A

Front desk can enter incorrect payer when setting up demographics for patient

99
Q

Error in the denial or appeal process:

Is it a bill error, rejection, or ____?

A

Denial

100
Q

Errors in the denial or appeal process:

Understanding ____ vs. cancelling a claim

A

Correcting

101
Q

Errors in the denial or appeal process:

The biggest problems with handling denials properly are ____ and following the payer’s specific instructions and guidelines for correcting claims and for the appeal process

A

Timing

102
Q

Errors in the denial or appeal process:

Poor ____, internally and externally, is also obstacles to clean claims

A

Communication

103
Q

Errors in the denial or appeal process:

Maintain solid ____ with provider representatives

A

Relationships

104
Q

Typically, there is a ____ relationship between total charges, payments, and adjustments

A

Proportionate

105
Q

If adjustments are up when payments are down, what is this?

A

A red flag

106
Q

Any change in the overall percentage of adjustments relative to other posting activity should be ____

A

Investigated

107
Q

If charges go up, what should happen to payments?

A

Payments should also go up

108
Q

Red flag would be when charge and adjustments are ____ but payments are ____

A

Up, down

109
Q

If adjustments are ____ but payments are ____, there’s a big red flag!

A

Up, down

110
Q

Common collection and payment errors:

Errors in ____ payments and adjustments

A

Posting

111
Q

Common collection and payment errors:

Adjustment and payment ____ misleading

A

Categories

112
Q

Common collection and payment errors:

Posting guidelines, ____ and ____, benchmarks not in place

A

Checks and balances

113
Q

Common collection and payment errors:

Errors created by ____ posting of remittance advices

A

Electronic

114
Q

Common collection and payment errors:

Failure to reconcile A/R activity in system to ____ ____ ____, actual deposits, and EFTs. Use your system reports and tools.

A

Daily cash reports

115
Q

Common collection and payment errors:

Not collection or assigning ____, ____, or ____ amounts at the time of service

A

Copays, deductibles, and coinsurance

116
Q

Common collection and payment errors:

Not having established, written ____ policies

A

Financial

117
Q

Common collection and payment errors:

Not enforcing or following up with ____ plans

A

Payment

118
Q

Common collection and payment errors:

Not sending statements in a ____ manner

A

Timely

119
Q

Common collection and payment errors:

____ and communication with patients about their financial responsibility to their care

A

Transparency

120
Q

True or False:

It’s important to collect copays, deductible, and coinsurance amounts upfront because the chance of collecting on the backend is diminshed

A

True

121
Q

What should be established and communicated when contracting with 3rd parties for billing, AR, and collection services?

A

Clear, objective expectations

122
Q

You must have written financial policies for collection processes, bad debt write-off, and cost report treatment of bad debt. All ____ ____ must be managed using the same guidelines.

A

Financial classes

123
Q

Why should credit balances be investigated in a timely manner?

A

To determine if the amount was created by a posting error or if overpayment was received

124
Q

Strive to have a ____ A/R

A

Clean

125
Q

True or False:

The older a balance is, the harder it is to collect

A

True

126
Q

Why should you solicit feedback from your team regarding performance improvement in the revenue cycle?

A

They interact with patients every day or bill/code claims so they are a great resource

127
Q

If you are capturing charges at the same time you’re providing services, you have a ____ workflow

A

Efficient

128
Q

Total amount of all outstanding patient balances; may include total charges for accounts not yet paid or adjusted; may include both insurance balances or patient responsibility balances

A

Accounts receivable

129
Q

The gold standard for the revenue cycle is that the payment window should be no more ____ days on primary claim

A

45 days

130
Q

True or False:

The payment window could be as short as 2 weeks

A

True

131
Q

A calculation of how long it takes on overage to collect one day’s revenue. The calculation can be based on either gross or net amount of revenue.

A

AR Days

132
Q

Before EDI and ET, we could expect AR Days to be between ____-____ day, but now we can expect a much shorter time period for clean claims

A

45 to 60 days

133
Q

How do you calculate AR Days?

A

Total AR for a given period / the average daily patient service revenue for the same period

134
Q

Account aging represents the outstanding AR amounts assigned to aging bucket based on how many days have elapsed since when?

A

The original DOS

135
Q

The aging can represent ____ or ____ balances

A

Patient or insurance

136
Q

AR amounts which have been determined to be uncollectible

A

Bad debt

137
Q

The difference between the gross charge and the amount we have agreed to receive for the service based on contract or agreements with a payer

A

Contractual adjustment

138
Q

Amounts adjusted off of the gross charge for reasons other than contractual adjustments.

A

Other adjustments

139
Q

How should posting categories be set up?

A

In a way that helps us identify problems, trends, or external/internal issues

140
Q

Amounts posted which represent cash payments from either the patient or a 3rd party (amount we get in the door)

A

Payments

141
Q

What is the below an example of?

Agreed to $100/visit with a commercial payer. The charge for the visit is $150, but we receive $100.

A

A contractual adjustment

142
Q

Amounts posted which reduce the balance but do not represent a transaction from a direct payment source

A

Credit

143
Q

The results or posting more adjustments, payments, and credits which exceed the dollar amount of gross charges

A

Credit balance

144
Q

The credit balance may represent a true ____ or can result from posting errors

A

Overpayment

145
Q

The credit balance may represent a true overpayment or can result from ____ errors

A

Posting

146
Q

It is important to understand the ____ ____ limit for each of the insurance carriers you work with

A

Timely filing

147
Q

What is the timely filing limit for Medicare?

A

365 days

148
Q

True or False:

The timely filing limit for all carriers if 365 days

A

False; Medicare is 365 days. Know the timely filing limit for each of your carriers!

149
Q

Some carriers will have ____-day timely filing limits

A

90-day

150
Q

It is recommended that you keep track of timely filing limits for each carrier you work with using what method?

A

Spreadsheet

151
Q

True or False:

Even though claims are submitted electronically, there are still a lot of issues with timely filing for most clinics

A

False; rarely have problems, except with new RHCs are everything is being set up

152
Q

For almost all Medicaid plans, there will be a ____ between state and managed plans with a prescribed way to escalate a problem

A

Liaison

153
Q

RHCs can expect payment for services within ____ days of a clean claim being filed for most primary payers

A

30 days

154
Q

Your MAC will automatically hold all of your RHC claims for a ____-day minimum

A

14 day

155
Q

Why is online access to insurance companies high recommended?

A

To easily review payments and/or claim issues that have arisen

156
Q

Why is enrolling in EFT a great way to better manage your revenue cycle?

A

It allows for quicker payment of claims

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