Rev Cycle Flashcards
The disadvantages of outsourcing include all of the following EXCEPT
The impact of customer service or patient relations
The impact of loss of direct control of accounts receivable services
Increased costs due to vendor ineffectiveness
Reduced internal staffing costs and a reliance on outsourced staff
Reduced internal staffing costs and a reliance on outsourced staff
The Medicare fee-for service appeal process for both beneficiaries and providers includes all of the following levels EXCEPT:
Medical necessity review by an independent physician’s panel
Judicial review by a federal district court
Redetermination by the company that handles claims for Medicare
Review by the Medicare Appeals Council (Appeals Council)
Judicial review by a federal district court
Business ethics, or organizational ethics represent:
The principles and standards by which organizations operate
Regulations that must be followed by law
Definitions of appropriate customer service
The code of acceptable conduct
The principles and standards by which organizations operate
Business ethics, or organizational ethics represent:
The principles and standards by which organizations operate
Regulations that must be followed by law
Definitions of appropriate customer service
The code of acceptable conduct
The principles and standards by which organizations operate
portion of the accounts receivable inventory which has NOT qualified for billing includes:
Charitable pledges
Accounts created during pre-registration but not activated
Accounts coded but held within the suspense period
Accounts assigned to a pre-collection agency
Charitable pledges
Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) are Medicare established guideline(s) used to determine:
Medicare and Medicaid provider eligibility
Medicare outpatient reimbursement rates
Which diagnoses, signs, or symptoms are reimbursable
What Medicare reimburses and what should be referred to Medicaid
Which diagnoses, signs, or symptoms are reimbursable
Days in A/R is calculated based on the value of:
The total accounts receivable on a specific date
Total anticipated revenue minus expenses
The time it takes to collect anticipated revenue
Total cash received to date
The time it takes to collect anticipated revenue
Patients are contacting hospitals to proactively inquire about costs and fees prior to agreeing to service. The problem for hospitals in providing such information is:
That hospitals don’t want to establish a price without knowing if the patient has insurance and how much reimbursement can be expected
The fact that charge master lists the total charge, not net charges that reflect charges after a payer’s contractual adjustment
That hospitals don’t want to be put in the position of “guaranteeing” price without having room for additional charges that may arise in the course of treatment
Their reluctance to share proprietary information
The fact that charge master lists the total charge, not net charges that reflect charges after a payer’s contractual adjustment
Across all care settings, if a patient consents to a financial discussion during a medical encounter to expedite discharge, the HFMA best practice is to:
Make sure that the attending staff can answer questions and assist in obtaining required patient financial data
Have a patient financial responsibilities kit ready for the patient, containing all of the required registration forms and instructions
Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow
Decline such request as finance discussions can disrupt patient care and patient flow
Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow
comprehensive “Compliance Program” is defined as
Annual legal audit and review for adherence to regulations
Educating staff on regulations
Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met
The development of operational policies that correspond to regulations
Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met
Case Management requires that a case manager be assigned
To patients of any physician requesting case management
To a select patient group
To every patient
To specific cases designated by third party contractual agreement
To a select patient group
Pricing transparency is defined as readily available information on the price of healthcare services, that together with other information, help define the value of those services and enable consumers to
Identify, compare, and choose providers that offer the desired level of value
Customize health care with a personally chosen mix of providers
Negotiate the cost of health plan premiums
Verify the cost of individual clinicians
Identify, compare, and choose providers that offer the desired level of value
Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons based on a monthly fee is known as a
MSO
HMO
PPO
GPO
HMO
In a Chapter 7 Straight Bankruptcy filing
The court liquidates the debtor’s nonexempt property, pays creditors, and discharges the debtor from the debt
The court liquidates the debtor’s nonexempt property, pays creditors, and begins to pay off the largest claims first. All claims are paid some portion of the amount owed
The court vacates all claims against a debtor with the understanding that the debtor may not apply for credit without court supervision
The court establishes a creditor payment schedule with the longest outstanding claims paid first
The court liquidates the debtor’s nonexempt property, pays creditors, and discharges the debtor from the debt
The core financial activities resolved within patient access include:
Scheduling, pre-registration, insurance verification and managed care processing
Scheduling, insurance verification, clinical discharge processing and payment posting of point of service receipts
Scheduling, registration, charge entry and managed care processing
Scheduling, pre-registration, registration, medical necessity screening and patient refunds
Scheduling, pre-registration, insurance verification and managed care processing
Which of the following is NOT contained in a collection agency agreement?
A clear understanding that the provider retains ownership of any outsourced activities
Specific language as to who will pay legal fees, if needed
An annual renewal clause
A mutual hold-harmless
A mutual hold-harmless clause
Maintaining routine contact with the health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of:
Patient Accounts
Managed Care Contract Staff
HIM staff
Case Management
Case Management
What is required for the UB-04/837-I, used by Rural Health Clinics to generate payment from Medicare?
Revenue codes
Correct Part A and B procedural codes
The CMS 1500 Part B attachment
Medical necessity documentation
Revenue codes
Before classifying and subsequently writing off an account to financial assistance or bad debt, the hospital must establish policy, define appropriate criteria, implement procedures for identifying and processing accounts:
Monitor compliance
Have the account triaged for any partial payment possibilities
Assist in arranging for a commercial bank loan
Obtain the patients income tax statements from the prior 2 years
Monitor compliance
For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions:
Are optional
Should take place between the patient or guarantor and properly trained provider representatives
May take place between the patient and discharge planning
Are focused on verifying required third-party payer information
Should take place between the patient or guarantor and properly trained provider representatives
The purpose of a financial report is to:
Provide a public record, if reqluested
Present financial information to decision makers
Prepare tax documents
Monitor expenses
Present financial information to decision makers
Which statement is an EMTALA (Emergency Medical Treatment and Active Labor Act) violation?
Registration staff may routinely contact managed are plans for prior authorizations before the patient is seen by the on-duty physician
Initial registration activities may occur so long as these activities do not delay treatment or suggest that treatment with not be provided to uninsured individuals
Co-payments may be collected at the time of service once the medical screening and stabilization activities are completed
Signage must be posted where it can be easily seen and read by patients
Registration staff may routinely contact managed are plans for prior authorizations before the patient is seen by the on-duty physician
claim is denied for the following reasons, EXCEPT:
The health plan cannot identify the subscriber
The frequency of service was outside the coverage timeline
The submitted claim does not have the physicians signature
The subscriber was not enrolled at the time of service
The submitted claim does not have the physicians
Any provider that has filed a timely cost report may appeal an adverse final decision received from the Medicare Administrative Contractor (MAC). This appeal may be filed with
A court appointed federal mediator
The Department of Health and Human Services Provider Relations Division
The Office of the Inspector General
The Provider Reimbursement Review Board
The Provider Reimbursement Review Board
Charges, as the most appropriate measurement of utilization, enables
Generation of timely and accurate billing
Managing of expense budgets
Accuracy of expense and cost capture
Effective HIM planning
Ambulance services are billed directly to the health plan for
All pre-admission emergency transports
Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility
The portion of the bill outside of the patient’s self-pay
Transports deemed medically necessary by the attending paramedic-ambulance crew
The portion of the bill outside of the patient’s self-pay
