Denials and Appeals

Question 1

In most healthcare systems, case managers are isolated from the financial side of the business, lacking key details and relationships that could have a significant impact on the revenue cycle.
True or False

Answer 1

True

Question 2

Up to two in five claims is delayed or denied.

True or False

Answer 2

False

Question 3

Inpatient hospital admissions are denied more often for a lack of prior authorization than because of failure to notify the plan of a non-elective admission.
True or False

Answer 3

False

Question 4

A key feature of a robust denial management program is the classification of denials by root causes rather than simply by the payers’ denial reasons.
True or False

Answer 4

True

Question 5

The revenue cycle team must break down the data to produce optimal approaches at both the case management and service levels to minimize lost revenue from medical necessity denials.
True or False

Answer 5

True

Question 6

The team efforts should directly align with the organization’s mission to provide high-quality care.
True or False

Answer 6

True

Question 7

What is the ultimate goal of denial management?
A.  Maximize revenues
B.  Minimize Expenses
C.  Maximizing processing claims
D.  Both A and B

Answer 7

D. Both A and B

Question 8

Typical Causes of denials are?
A.  Excessive data
B.  Incorrect Coding
C.  Legible Hand-written notes
D.  Use of EHR

Answer 8

B. Incorrect Coding

Question 9

Which of the following is TRUE about an appeal of a denial?
A. An appeal is an action taken when a provider or patient disagrees with a payment decision
B. The right of appeal rests with the facility
C. There are 3 levels of appeals in the process with specific requirements for each of them
D. There are 4 levels of appeals in the Medicare process with specific timeframes for three of them as the 4th one is final

Answer 9

A. An appeal is an action taken when a provider or patient disagrees with a payment decision

Question 10

The most important aspect of the denials process is?
A.  Categorization
B.  Quantification
C.  Prevention
D.  Analysis

Answer 10

C. Prevention

Question 11

Commercial, Medicaid and Medicare Advantage all require?
A.  Scheduled processes
B.  Unplanned admissions
C.  Payer Plans
D.  Prior authorizations

Answer 11

D. Prior Authorizations

Question 12

The two types of medical necessity are?
A.  Planned service and level of care
B.  Scheduled and unscheduled
C.  Necessary and unnecessary
D.  Admission and observation

Answer 12

A. Planned service and level of care

Question 13

Which of the following accurately describes concurrent review?
A. Retrospective review once patient is discharged
B. Preparatory review before care is delivered
C. Ongoing review as care is delivered
D. Anticipatory review prior to care decisions and plans

Answer 13

C. Ongoing review as care is delivered.

Question 14

Medicare policy regarding healthcare coverage includes?
A. National coverage determinations exclusively
B. Both National and Local Coverage Determinations
C. Local Coverage Determinations priorities
D. Specific and Non-specific coverage determinations

Answer 14

B. Both National and Local Coverage Determinations

Question 15

A robust denials management program key feature is?
A. Classification of denials by root cause
B. Classification of denials by payer process
C. Rapidly following up on denials
D. Creating a database of payer denial reasons

Answer 15

A. Classification of denials by root cause

Question 16

Which of the following is NOT a denials data aggregation strategy?
A. Understanding and monitoring denials
B. Tracking, correcting, and appealing denials
C. Rapidly following up on denials
D. Creating a database of payer denial reasons

Answer 16

D. creating a database of payer denial reasons

Question 17

A primary strategy should be denials prevention. Which of the following is considered a front-end denial prevention strategy?
A. Ensure patient information is correct
B. Confirm pre-authorization information
C. Both A and B
D. Analyze denial data

Answer 17

C. Both A and B

Question 18

All of the following are elements of a denial management system EXCEPT?
A. communication of any/all changes in procedures or processes
B. Involvement of all physician offenders on the management team
C. Data Analytics
D. A clinical documentation improvement program

Answer 18

B. Involvement of all physician offenders on the management team

Question 19

Which of the following is TRUE regarding the inter-professional denials and appeals management team?
A. Diverse expertise is required to address all aspects of denials and appeals management
B. All members must posses strong business technology background
C. Ability to speak and understand inter-departmental data analytics is required
D. Only case managers possess the expertise required of denials and appeals management

Answer 19

A. Diverse expertise is required to address all aspects of denials and appeals management.

Question 20

The main components of a solid denial management process are?
A. Good data analytics
B. Good reporting
C. A cross-functional approach regarding corrective action
D. All of the above

Answer 20

D. All of the above

Question 21

Which of the following is crucial for an inter-professional denial and appeals team to function effectively?
A.  Empathy
B.  Emotional Intelligence
C.  Empowerment
D.  Change Theory

Answer 21

C. Empowerment