Rev Cycle 2 Flashcards
An individual enrolled in Medicare who is dissatisfied with the government’s claim determination is entitled to reconsideration of the decision. This type of appeal is known as
A beneficiary appeal
A Medicare supplemental review
A payment review
A Medicare determination appeal
A beneficiary appeal
The nuanced data resulting from detailed ICD-10 coding allows senior leadership to work with physicians to do all of the following EXCEPT:
Drive significant improvements in the areas of quality and the patient experience
Embrace new reimbursement models
Improve outcomes
Obtain higher compensation for physicians
Obtain higher compensation for physicians
Duplicate payments occur:
When providers re-bill claims based on nonpayment from the initial bill submission
When service departments do not process charges with the organization’s suspense days
When the payer’s coordination of benefits is not captured correctly at the time of patient registration
When there are other healthcare claims in process and the anticipated deductibles and co-insurance amounts still show open but will be met by the in-process claims
When providers re-bill claims based on nonpayment from the initial bill submission
The Affordable Care Act legislated the development of Health Insurance Exchanges, where individuals and small businesses can
Purchase qualified health benefit plans regardless of insured’s health status
Obtain price estimates for medical services
Negotiate the price of medical services with providers
Meet federal mandates for insurance coverage and obtain the corresponding
Purchase qualified health benefit plans regardless of insured’s health status
The most common resolution methods for credit balances include all of the following EXCEPT:
Designate the overpayment for charity care
Submit the corrected claim to the payer incorporating credits
Either send a refund or complete a takeback form as directed by the payer
Determine the correct primary payer and notify incorrect payer of overpayment
Designate the overpayment for charity care
EFT (electronic funds transfer) is
An electronic claim submission
The record of payments in the hospital’s accounting system
An electronic confirmation that a payment is due
An electronic transfer of funds from payer to payee
An electronic transfer of funds from payer to payee
Revenue cycle activities occurring at the point-of-service include all of the following EXCEPT:
The monitoring of charges
The provision of case management and discharge planning services
Providing charges to the third-party payer as they are incurred
The generation of charges
Providing charges to the third-party payer as they are incurred
Medicare beneficiaries remain in the same “benefit period”
Up to hospitalization discharge
Until the beneficiary is “hospitalization and/or skilled nursing facility-free” for 60 consecutive days
Each calendar year
Up to 60 days
Until the beneficiary is “hospitalization and/or skilled nursing facility-free” for 60 consecutive days
Key Performance Indicators (KPIs) set standards for accounts receivables (A/R) and
Provide evidence of financial status
Provide a method of measuring the collection and control of A/R
Establish productivity targets
Make allowance for accurate revenue forecasting
Provide a method of measuring the collection and control of A/R
Recognizing that health coverage is complicated and not all patients are able to navigate this terrain, HFMA best practices specify that
The patient accounts staff have someone assigned to research coverage on behalf of patients
Patients should be given the opportunity to request a patient advocate, family member, or other designee to help them in these discussions
Patient coverage education may need to be provided by the health plan
A representative of the health plan be included in the patient financial responsibilities discussion
Patients should be given the opportunity to request a patient advocate, family member, or other designee to help them in these discussions
When there is a request for service, the scheduling staff member must confirm the patient’s unique identification information to
Check if there is any patient balance due
Verify the patient’s insurance coverage if the patient is a returning customer
Confirm that physician orders have been received
Ensure that she/he accesses the correct information in the historical database
Ensure that she/he accesses the correct information in the historical database
Once the price is estimated in the pre-service stage, a provider’s financial best practice is to
Explain to the patient their financial responsibility and to determine the plan for payment
Allow the patient time to compare prices with other providers
Lock-in the prices
Have another employee double check the price estimate
Explain to the patient their financial responsibility and to determine the plan for payment
What type of account adjustment results from the patient’s unwillingness to pay a self-pay balance?
Charity adjustment
Bad debt adjustment
Contractual adjustment
Administrative adjustment
Bad debt adjustment
All of the following are conditions that disqualify a procedure or service from being paid for by Medicare EXCEPT
Medically unnecessary
Not delivered in a Medicare licensed care setting
Offered in an outpatient setting
Services and procedures that are custodial in nature
Services and procedures that are custodial in nature
All of the following are forms of hospital payment contracting EXCEPT
Contracted Rebating
Per Diem Payment
Fixed Contracting
Bundled Payment
Contracted Rebating
Overall aggregate payments made to a hospice are subject to a computed “cap amount” calculated by:
The Center for Medicare and Medicaid Services (CMS)
Each state’s Medicaid plan
Medicare
The Medicare Administrative Contractor (MAC) at the end of the hospice cap period
The Medicare Administrative Contractor (MAC) at the end of the hospice cap period
With the advent of the Affordable Care Act Health Insurance Marketplaces and the expansion of Medicaid in some states, it is more important than ever for hospitals to
Reschedule the visit for non-payment of a prior balance
Strictly limit charity care and bad-debt
Collect patient’s self-pay and deductibles in the first encounter
Assist patients in understanding their insurance coverage and their financial obligati
Assist patients in understanding their insurance coverage and their financial obligation
A nightly room charge will be incorrect if the patient’s
Discharge for the next day has not been charted
Condition has not been discussed during the shift change report meeting
Pharmacy orders to the ICU have not been entered in the pharmacy system
Transfer from ICU (intensive care unit) to the Medical/Surgical floor is not reflected in the registration system
Transfer from ICU (intensive care unit) to the Medical/Surgical floor is not reflected in the registration system
Which of the following is required for participation in Medicaid?
Meet income and assets requirements
Meet a minimum yearly premium
Be free of chronic conditions
Obtain a health insurance policy
Meet income and assets requirements
HFMA best practices call for patient financial discussions to be reinforced
By issuing a new invoice to the patient
By copying the provider’s attorney on a written statement of conversation
By obtaining some type of collateral
By changing policies to programs
By copying the provider’s attorney on a written statement of conversation
A Medicare Part A benefit period begins
With admission as an inpatient
The first day in which an individual has not been a hospital inpatient not in a skilled nursing facility for the previous 60 days
Upon the day the coverage premium is paid
Immediately once authorization for treatment is provided by the health plan
With admission as an inpatient
If further treatment can only be provided in a hospital setting, the patient’s condition cannot be evaluated and/or treated within 24 hours, or if there is not an anticipation of improvement in the patient’s condition with 24 hours, the patient
Will remain in observation for up to 72 hours after which the patient is admitted as an inpatient
Will be admitted as an inpatient
Will be discharged and if needed, designated to a priority one outpatient status
Will have his/her case reviewed by the attending physician, a consulting physician and the primary care physician and a future course of care will then be determined
Will be admitted as an inpatient
It is important to have high registration quality standards because
Incomplete registrations will trigger exclusion from Medicare participation
Incomplete registrations will raise satisfaction scores for the hospital
Inaccurate registration may cause discharge before full treatment is obtained
Inaccurate or incomplete patient data will delay payment or cause denials
Inaccurate or incomplete patient data will delay payment or cause denials
Medicare will only pay for tests and services that
Constitute appropriate treatment and are fairly priced
Have solid documentation
Can be demonstrated as necessary
Medicare determines are “reasonable and necessary”
From the midnight census
