Ch. 1 Overview of Revenue Cycle

Question 1

revenue cycle is the

Answer 1

life cycle of a payment claim that begins when the patient checks in at the front desk and ends after all payments or denials and appeals have been made

Question 2

revenue cycle management consist of

Answer 2

all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue

Question 3

health care reimbursement began in

Answer 3

1930s
texas at baylor universisty

Question 4

in 1965 the social security act was amended to add?

Answer 4

medicare and medicaid

Question 5

challenges that face US health care system

Answer 5

-rising health care cost
-need to improve quality and safety
-need to improve coordination and accountability of care and service between providers and payers (the system is complex so its vital that claims are accurate)

Question 6

HIPPA

Answer 6

covers the way healthcare plans and providers exchange information as they conduct business
prohibits HCP from disclosing PHI without Pt consent

Question 7

health care clearinghouses

Answer 7

converts nonstandard transactions into standard transactions and transmit data to health plans (only hippa covered entity that can check claims from doctors from errors)

Question 8

covered entities (CE)

Answer 8

healthcare organizations required to comply with HIPPA

Question 9

Protected Health Information (PHI) includes things like

Answer 9

name
dob
email and residential address
account number
etc

Question 10

HIPPA allows release without pt authorization with

Answer 10

treatment
payment
health care operations
to ensure public health and safety

Question 11

ePHI

Answer 11

all individually health information a CE creates, recieves, maintains, or transmits in electronic form

Question 12

The Security Rule

Answer 12

requires CEs to maintain reasonable and appropriate administrative, technical, and physical safeguards

Question 13

minimum necessary

Answer 13

disclosures to other HCP for treatment purposes must be only the minimum amount of PHI needed to accomplish intended purpose

Question 14

Medicare integrity program

Answer 14

looks over providers’ claims and payments to find fraud or abuse

Question 15

false claims act

Answer 15

prohibit federal contractors from knowingly filing a fraudulent claim

Question 16

medicare/medicaid patient and program protection act 1987

Answer 16

added fines for any Medicare/Medicaid fraud

Question 17

operation restore trust

Answer 17

1985- target HCP for committing fraud and abuse

Question 18

fraud

Answer 18

knowingly submitting false claims or making misrepresentations to obtain payment for which no entitlement otherwise exists (cms.gov)

Question 19

abuse

Answer 19

practices that directly or indirectly result in unnecessary costs to Medicare (cms.gov)

Question 20

Front-end revenue cycle

Answer 20

payer negotiation
Appointment scheduling
insurance verification

Question 21

middle end of the revenue cycle

Answer 21

patient is seen
charges captured on the encounter form
transferred to CMS-1500 Claim form
claims transmitted electronically to clearinghouse

Question 22

Back-end revenue cycle

Answer 22

payment received, posted to accounts receivable
denied claims examined for coding error/missing data
claims adjudication, remittance advice, explanation of benefits

Question 23

clean claim

Answer 23

claim completed correctly with no errors or omissions

Question 24

Claims adjudication

Answer 24

Process in which, upon receipt of a claim, the payer compares the claim to payer edits and the patient’s health plan benefits to verify that all required information is available to process the claim, that the claim is not a duplicate submission, and that the procedures performed or services provided are covered benefit

Question 25

Capitation

Answer 25

pre-established fixed payment per patient per unit of time in advance to the physician

Question 26

fee schedule

Answer 26

predetermined list of fees that the payer allows for the payment of all health care services

Question 27

Health information management role

Answer 27

ensure accurate documentation support codes assigned

Question 28

medical record documentation

Answer 28

health record EMR/PHYSICAL: is the property of a hospital, clinic, health care organization
health information provided: is owned by the patient

Question 29

Clinical classification systems

Answer 29

used for reimbursement, public health reporting, quality of care assessment, education, research, and monitoring performance
i.e ICD-10-CM/PCS

Question 30

Clinical terminologies

Answer 30

provide common reference points for comparison and collection of data about the entire healthcare process, recorded by multiple different individuals, systems, healthcare care organization
i.e SNOMED CT

Question 31

Artificial intelligence (AI)

Answer 31

used to fill in the gaps and cut costs In the revenue cycle
technology that use machine learning algorithm and software to mimic human cognition

Question 32

Robotic Process Automation

Answer 32

automation of repetitive tasks in the workflow

Question 33

Predictive analytics

Answer 33

used to forecast or predict revenue
to correct problems before they occur

Question 34

revenue cycle management chart flow

Answer 34

physician ordering
patient registration
charge captured
diagnosis/procedure, coding/auditing
patient discharge processing
billing/claims processing
resubmitting claims
3rd party payer reimbursement posting
appeals process
patient billing
self-pay reimbursement posting
collections
collections reimbursement posting

Question 35

copay

Answer 35

A provision in the insurance policy that requires the policyholder (patient) to pay a specified dollar amount to a heath care provider for each visit or medical service received.

Question 36

coinsurance

Answer 36

The percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.

Question 37

deductibles

Answer 37

An amount for which the patient is financially responsible before the insurance policy pays.

Question 38

third party payer

Answer 38

An insurance company that patients have a contract with to provide coverage for health services.

Question 39

remittance advice

Answer 39

statement summary prepared by the insurance carrier, usually in batch form containing multiple patients/beneficiaries, received by the provider to explain what the plan has paid on each beneficiary claim covered by their plan. This information includes the charge, the allowed amount, the amount paid by the insurance, the co-insurance responsibility, and the amount the patient is responsible for paying.

Question 40

explanation of benefits

Answer 40

A statement summary received by the patient that explains what the insurance plan has paid to the provider. It also lists the plan deductible that the patient has met and what their out-of-pocket expenses are.