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LATEST VERSION VERIFIED RATIONALE GRADED
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With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what? - ansAccess their information and perform functions on-line Why does the financial counselor need pricing for services? - ansTo calculate the patient's financial responsibility Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - ansTo improve access to quality healthcare When is the word "SAME" entered on the CMS 1500 billing form in Field 0$? - ansWhen the patient is the insured When is it not appropriate to use observation status? - ansAs a substitute for an inpatient admission When does a hospital add ambulance charges to the Medicare inpatient claim? - ansIf the patient requires ambulance transportation to a skilled nursing facility When an undue delay of payment results from a dispute between the patient and the third party payer, who is responsible for payment? - ansPatient When a patient's illness results in an unusually high amount of medical bills not covered by insurance or other patient pay resources, what type of account is created - anscatastrophic charity When a patient reports directly to a clinical department for service, what will the clinical department staff do? - ansRedirect the patient to the patient access department for registration What will comprehensive patient access processing accomplish? - ansMinimize the need for follow-up on insurance accounts What will cause a CMS 1500 claim to be rejected? - ansThe provider is billing with a future date of service What type of provider bills third-party payers using CMS 1500 form - ansHospital-based mammography centers What type of patient status is used to evaluate the patient's need for inpatient care? - ansObservation What type of account adjustment results from the patient's unwillingness to pay for a self-pay balance? - ansBad debt adjustment What technique is acceptable way to complete the MSP screening for a facility situation? - ansAsk if the patient's current services was accident related What statement DOES NOT apply to revenue codes? - ansrevenue codes identify the payer
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What statement describes the APC (Ambulatory payment classification) system? - ansAPC rates are calculated on a national basis and are wage-adjusted by geographic region What statement applies to the scheduled outpatient? - ansThe services do not involve an overnight stay What standard claim forms are currently used by the healthcare industry to submit claims to third-party payers? - ansThe UB-04 and the CMS 1500 What should the provider do if both of the patient's insurance plans pay as primary? - ansDetermine the correct payer and notify the incorrect payer of the processing error What service provided to a Medicare beneficiary in a rural health clinic (RHC) is not billable as an RHC services? - ansInpatient care What results from a denied claim? - ansThe provider incurs rework and appeal costs What restriction does a managed care plan place on locations that must be used if the plan is to pay for the services provided? - ansSite-of-service limitation what protocol was developed through the Patient Friendly Billing Project? - ansProvide information using language that is easily understood by the average reader What process can be used to shorten claim turnaround time? - ansSend high-dollar hard-copy claims with required attachments by overnight mail or registered mail what organization originated the concept of insuring prepaid health care services? - ansBlue Cross and blue Shield What option is an alternative to valid long-term payment plans? - ansBank loans What must a provider do to qualify an account as a Medicare bad debts? - ansPursue the account for 120 days and then refer it to an outside collection agency What MSP situation requires LGHP - ansDisability What items are valid identifiers to establish a patient's identification? - ansPhoto identification, date of birth, and social security number What is true of the information the provider supplies to indicate that an authorization for service has been received from the patient's primary payer? - ansIt is posted on the remittance advice by the payer What is true about screening a beneficiary for possible MSP situations? - ansIt is acceptable to complete the screening form after the patient has completed the registration process and been sent to the service department
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What is a CCO - ansChief compliance officer - they typically report directly to the board of directors/trustees as well as the chief executive officer, and has limited responsibilities for other operational aspects of the organization What is a benefit of pre-registering patient's for service? - ansPatient arrival processing is expedited, reducing wait times and delays What is a benefit of insurance verification? - ansPre-certification or pre-authorization requirements are confirmed What is a benefit of electronic claims processing? - ansProviders can electronically view patient's eligibility What happens when a patient receives non-emergent services from and out-of-network provider? - ansPatient payment responsibility is higher What form is used to bill Medicare for rural health clinics? - ansCMS 1500 What does scheduling allow provider staff to do - ansReview appropriateness of the service request What does Medicare Part D provide coverage for? - ansPrescription drugs What do the MSP disability rules require? - ansThat the patient's spouse's employer must have less than 20 employees in the group health plan What do large adjustments require? - ansManager-level approval What do EMTALA regulations require on-call physicians to do? - ansPersonally appear in the emergency department and attend to the patient within a reasonable time What date is required on all CMS 1500 claim forms? - ansonset date of current illness What data are required to establish a new MPI entry? - ansThe patient's full legal name, date of birth, and sex What customer service improvements might improve the patient accounts department? - ansHolding staff accountable for customer service during performance reviews What core financial activities are resolved within patient access? - ansScheduling, insurance verification, discharge processing, and payment of point-of-service receipts What code is used to report the provider's most common semiprivate room rate? - ansCondition code What code indicates the disposition of the patient at the conclusion of service? - ansPatient discharge status code
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What circumstance would result in an incorrect nightly room charge? - ansIf the patient's discharge, ordered for tomorrow, has not been charted What areas does the code of conduct typically focus on? - ansHuman resources. Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest. Laws/regulations What are the two statutory exclusions from hospice coverage? - ansMedically unnecessary services and custodial care What are the situations where another payer may be completely responsible for payment? - ansWork- related accidents, black lung program services, patient is enrolled in Medicare Advantage, Federal grant programs What are some core elements of a board-approved financial policy - ansCharity care, payment methods, and installment payment guidelines What are non-emergency patients who come for service without prior notification to the provider called? - ansUnscheduled patients What are hospitals required to do for Medicare credit balance accounts? - ansThey result in lost reimbursement and additional cost to collect What are collection agency fees based on? - ansA percentage of dollars collected What activities are completed when a scheduled pre-registered patient arrives for service? - ansRegistering the patient and directing the patient to the service area Value - ansThe quality of a healthcare service in relation to the total price paid for the service by care purchasers Utilization review - ansReview conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Usual, customary, and reasonable (UCR) - ansHealth insurance plan reimbursement methodology that limits payment to the lower billed charges, the provider's customary charge, or the prevailing charge for the service in the community Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information? - ansObtain the required demographic and insurance information before services are rendered Under Medicare rules, certain outpatient services that are provided within three days of the admission date, by hospitals or by entities owned or controlled by hospitals, must be billed as part of an inpatient stay. - ansTRUE
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Providers who are found to be in violation of CMS regulations are subject to: - ansCorporate integrity agreements Provider - ansAn entity, organization, or individual that furnishes a healthcare service Price transparency - ansIn health care, readily available information on the price of healthcare services that, together, with other information helps define the value of those services and enables patients and other care purchasers to identify, compare, and choose providers that offer the desired level of value Price - ansthe total amount a provider expects to be paid by payers and patients for healthcare services Pre-existing condition limitation - ansA restriction on payments for charges directly resulting from a pre- existing health conditions Pre-admission review - ansthe practice of reviewing requests for inpatient admission before the patient is admitted to ensure that the admission is medically necesary Payer - ansAn organization that negotiates or sets rates for provider services, collects revenue through premium payments or tax dollars, processes provider claims for service, and pays provider claims using collected premium or tax revenues Out-of-pocket payments - ansCash payments made by the insured for services not covered by the health insurance plan Out-of-area benefits - anshealthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out of pocket payment - ansThe portion of the total payment for medical services and treatment for which the patient is responsible, including copayments, coinsurance, and deductibles Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: - ansA valid CPT or HCPCS code Medically necessary - ansHealthcare services that are required to preserve or maintain a person's health status in accordance with medical practice standards Insurance verification results in what? - ansThe accurate identification of the patient's eligibility and benefits Indemnity insurance - ansnegotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - ansCase rates
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In services lines such as cardiology or orthopedics, what does the case-rate payment methodology allow providers to do? - ansReceive a fixed for specific procedures In addition to being supported by information found in the patient's chart, a CMS 1500 claim must be coded using what? - ansHCPCS (Healthcare Common Procedure Coding system) If the patient cannot agree to payment arrangements, what is the next option? - ansWarn the patient that unpaid accounts are placed with collection agencies for further processing If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - ansNeither enrolled not entitled to benefits IF outpatient diagnostic services are provided within three days of the admission of a Medicare beneficiary to an IPPS (Inpatient Prospective Payment System) hospital, what must happen to these charges - ansThey must be combined with the inpatient bill and paid under the MS-DRG system If a patient remains an inpatient of an SNF (skilled nursing facility for more than 30 days, what is the SNF permitted to do? - ansSubmit interim bills to the Medicare program. If a patient declares a straight bankruptcy, what must the provider do? - ansWrite off the account to the contractual adjustment account If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - ansDiagnostic and clinically-related non-diagnostic charges provided on the Tuesday, Wednesday, Thursday, and Friday before admission How should a provider resolve a late-charge credit posted after an account is billed? - ansPost a late- charge adjustment to the account How must providers handle credit balances? - ansComply with state statutes concerning reporting credit balance How may a collection agency demonstrate its performance? - ansCalculate the rate of recovery How is a mis-posted contractual allowance resolved? - ansComparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount How does utilization review staff use correct insurance information? - ansTo obtain approval for inpatient days and coordinate services How are patient reminder calls used? - ansTo make sure the patient follows the prep instructions and arrives at the scheduled time for service
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Case management - ansThe process whereby all health-related components of a case are managed by a designated health professional. Intended to ensure continuity of healthcare accessibility and services Care purchaser - ansIndividual or entity that contributes to the purchase of healthcare services At the end of each shift, what must happen to cash, checks, and credit card transaction documents? - ansThey must be balanced an increase in the dollars aged greater than 90 days from date of service indicate what about accounts - ansThey are not being processed in a timely manner Administrative Services Only (ASO) - ansUsually contracted administrative services to a self-insured health plan According to the Department of Health and Human Services guidelines, what is NOT considered income?
- ansSale of property, house, or car Access - ansAn individual's ability to obtain medical services on a timely and financially acceptable level
- MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - ans120 days passes, but the claim then be withdrawn from the liability carrier
LATEST VERSION VERIFIED RATIONALE GRADED
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LATEST VERSION VERIFIED RATIONALE GRADED
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LATEST VERSION VERIFIED RATIONALE GRADED
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LATEST VERSION VERIFIED RATIONALE GRADED
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