Denials and Appeals Flashcards
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
True
Up to two in five claims is delayed or denied.
True or False
False
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
False
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
True
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
True
The team efforts should directly align with the organization’s mission to provide high-quality care.
True or False
True
What is the ultimate goal of denial management? A. Maximize revenues B. Minimize Expenses C. Maximizing processing claims D. Both A and B
D. Both A and B
Typical Causes of denials are? A. Excessive data B. Incorrect Coding C. Legible Hand-written notes D. Use of EHR
B. Incorrect Coding
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
A. An appeal is an action taken when a provider or patient disagrees with a payment decision
The most important aspect of the denials process is? A. Categorization B. Quantification C. Prevention D. Analysis
C. Prevention
Commercial, Medicaid and Medicare Advantage all require? A. Scheduled processes B. Unplanned admissions C. Payer Plans D. Prior authorizations
D. Prior Authorizations
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
A. Planned service and level of care
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
C. Ongoing review as care is delivered.
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
B. Both National and Local Coverage Determinations
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
A. Classification of denials by root cause
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
D. creating a database of payer denial reasons
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
C. Both A and B
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
B. Involvement of all physician offenders on the management team
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
A. Diverse expertise is required to address all aspects of denials and appeals management.
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
D. All of the above
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
C. Empowerment
