CHFP Module 1 Certification Test Flashcards

Questions and Answers

The payment category that utilizes a payment based on a fixed amount per member per month (PMPM) is:

Bundled payments

Fee-for-service

Capitation (correct)

Per diem

Place the following steps in order for patient registration for an upper GI procedure:

1 = Gather demographic data from the patient 2 = Verify that the patient's information is updated and complete 3 = Contact the insurer 4 = Educate the patient about their financial responsibility to pay 5 = Ask how they would like to pay 6 = Collect the payment

Put the following during-visit activities in the correct order:

1 = Provide and document care to the patient 2 = Utilization review 3 = Change capture 4 = Discharge 5 = Medical record completion

Which of the following items might have been an error that resulted in a claim not being paid by the insurer?

There were duplicate E&M charges on the claim Signup and view all the answers

The ______ process the medical record to assign codes that describe the diagnosis of the patient's condition and the procedures performed during the patient visit.

coding Signup and view all the answers

Which of the following would be an obvious error in coding accuracy?

Showing a hysterectomy for a male patient Signup and view all the answers

The claim for payment (or bill) is referred to as the ______.

ANSI 837 Healthcare Claim Format Signup and view all the answers

Remittance advice sent from the health plan to the provider explaining the payment decision is also known as the ______.

ANSI 835 Healthcare Claim Payment/Advice Signup and view all the answers

The process where the health plan records the claim in its inventory of claims pending processing is known as ______.

claim logging Signup and view all the answers

The steps required by the health plan to process the claim for payment is collectively referred to as ______.

claims adjudication Signup and view all the answers

What are the steps in the payment processing?

Claim logging, eligibility, adjudication, remittance Signup and view all the answers

Which of the following items would not be needed for Kate to send a clean claim?

Copies of the patient's previous medical records Signup and view all the answers

Which of the following would be unimportant in determining why net days in receivables have increased over the past month?

The amount of time required for a new patient to get an appointment Signup and view all the answers

The combined activities of pre-visit, during-visit, and post-visit are known collectively as the:

Revenue cycle Signup and view all the answers

What is part of the process for clean review by a payer?

Adjudication cycle Signup and view all the answers

Which of the activities below is not a part of the pre-visit portion of the revenue cycle?

Coding Signup and view all the answers

Which of the terms below represent the payer's steps involved in payment processing (claims adjudication)?

Claims logging, eligibility, adjudication, remittance Signup and view all the answers

_____ is the intentional deception or misrepresentation of facts for gain. It carries criminal penalties.

Fraud Signup and view all the answers

________ involves unintentional actions (errors) that are inconsistent with accepted, sound medical, business or fiscal practices.

Abuse Signup and view all the answers

What is the goal of the compliance program?

To prevent fraud and abuse Signup and view all the answers

What is a chief enforcement vehicle of the federal government that allows the US Department of Health and Human Services to recover monetary damages for false claims?

False Claim Act Signup and view all the answers

Who is someone who discloses information he or she believes evidences violations of law or abuse?

Whistleblower Signup and view all the answers

What law protects patients' health and demographic information?

HIPAA Signup and view all the answers

What prohibits physician self-referrals for health services to entities with which the physician or their family has a financial relationship?

Stark I and II Signup and view all the answers

What makes it a criminal offense to offer remuneration for referrals?

Anti-Kickback Statute Signup and view all the answers

Which of the following is NOT a law or regulation with which healthcare entities must comply?

CHIP Signup and view all the answers

What term refers to the sources of cash given in working capital management?

Cash Signup and view all the answers

Working capital is the surplus of cash and near-cash items such as accounts receivable over current obligations.

Working capital management Signup and view all the answers

What represents a potential risk to Prairie Family Care if they accept capitation?

Potential losses from increases in service utilization Signup and view all the answers

Which of the following would be a priority for Charles Medical Center in forming a Medicare ACO?

Develop information systems Signup and view all the answers

What is a pre-determined amount that the patient pays before the insurer begins to pay for services?

deductible Signup and view all the answers

What is a percentage of the insurance payment amount that is paid by the patient?

coinsurance Signup and view all the answers

What is a flat amount that the patient pays at each time of service?

copayment Signup and view all the answers

What payment includes amounts for services that are not included in the patient's benefit design?

Out-of-pocket payment Signup and view all the answers

What is the amount payable out of pocket for healthcare services?

Cost (to the patient) Signup and view all the answers

What is the expense incurred to deliver healthcare services to patients?

Costs (to the provider) Signup and view all the answers

What is the amount payable to the provider for services rendered?

Cost (to the health plan/insurer) Signup and view all the answers

What is the expense related to provided health benefits?

Cost (to the employer) Signup and view all the answers

What does the provider set for services rendered before negotiating any discounts?

Charge Signup and view all the answers

What is the total amount a provider expects to be paid for healthcare services?

Price Signup and view all the answers

What organization negotiates rates for provider services?

Health Plan/Payer Signup and view all the answers

What entity furnishes a healthcare service?

Provider Signup and view all the answers

What occurs when a healthcare provider bills a patient for charges that exceed the health plan's payment?

Balance Billing Signup and view all the answers

What defines readily available information on the price of healthcare services?

Price Transparency Signup and view all the answers

What is the quality of healthcare service in relation to the total price paid for it?

Value Signup and view all the answers

What is the flow of money between the patient, the insurer, and the provider?

Revenue Cycle Signup and view all the answers

What function is one of the most important resource management challenges in today's healthcare industry?

Billing and Collection Signup and view all the answers

What term describes payment by an insurer to a healthcare provider after services are rendered?

Reimbursement Signup and view all the answers

What is the term for the price set by a healthcare facility for their services?

Charges or Billed Charges Signup and view all the answers

What are the charges by a healthcare facility or physician compiled in?

Chargemaster Signup and view all the answers

What describes a charge-based payment mechanism?

Fee-for-service Signup and view all the answers

What does fee-for-service payment provide?

more units of service in order to receive more payments. Signup and view all the answers

Why do healthcare facilities set retail prices significantly above rates actually paid?

Access to contracted payment rates and related factors. Signup and view all the answers

What is the use of cost-based payments?

Limited set of small rural healthcare facilities. Signup and view all the answers

What is the payment mechanism that has been nearly eliminated from the healthcare industry?

Cost based Payment Signup and view all the answers

Which healthcare provider benefits the most from a cost-based payment method?

The healthcare provider Signup and view all the answers

What payment method is least effective in stabilizing costs per patient?

Cost-based payment Signup and view all the answers

What are the five main types of prospective payments used in today's healthcare market?

DRG healthcare provider, Per Procedure, Case rate, Per diem, Bundled payment Signup and view all the answers

What payment is based on the patient's diagnosis?

(DRG) Diagnosis Related Group Signup and view all the answers

What is the most widely used payment method to healthcare providers?

(DRG)'s Signup and view all the answers

What classifies a disease or injury into approximately 750 different categories?

(DRG) Signup and view all the answers

What defines the increase or decrease adjustment to payment?

Relative weight Signup and view all the answers

What is the average level of severity of conditions of patients in a healthcare provider during a specified period?

case mix index Signup and view all the answers

A _________ pays a specified fee for each procedure performed on a patient.

Health plan Signup and view all the answers

What are the two payment approaches used in the per-procedure payment plan?

APC and RBRVS Signup and view all the answers

What payment approach is similar to the inpatient DRG?

APC Signup and view all the answers

What payment approach allows physician payment to vary based on resources needed?

Resource Based Relative Value Scale (RBRVS) Signup and view all the answers

__________ at 100% of the per-procedure fee.

Primary procedure Signup and view all the answers

_________ at 50% of the normal per-procedure fee.

Secondary procedure Signup and view all the answers

_________ 25% of the normal per-procedure fee.

Third and Subsequent procedure Signup and view all the answers

What are the common discounting approaches?

primary, secondary, and third/subsequent procedures Signup and view all the answers

What must a health plan have in place to control its risk of increased costs?

A utilization management program Signup and view all the answers

What is the predetermined amount paid to a healthcare provider for a specified service?

Case rate Signup and view all the answers

What is the difference between case rate and DRG?

Case rates encompass similar procedures while DRG can be specific to a diagnosis. Signup and view all the answers

Where is a common area where case rates would be used?

Cardiac surgery Signup and view all the answers

What payment system is used primarily for long-term care facilities?

Per diem payment system Signup and view all the answers

What health plan reimburses a facility a fixed amount per day?

per diem payment system Signup and view all the answers

What are the cons of the per diem system?

The rate may vary for different levels of service. Signup and view all the answers

What are the benefits of the per diem system?

It is administratively easy and provides predictable payment rates. Signup and view all the answers

What involves staff from the facility working with the health plan for patient review?

Concurrent review Signup and view all the answers

What is episodic payment in which all services provided are paid as a single rate?

bundled payment Signup and view all the answers

What are forms of risk-based contracts?

bundled payments and other shared savings Signup and view all the answers

What aligns the incentives of healthcare providers and physicians?

value-based payment Signup and view all the answers

What must be in place for acceptable financial results from a per diem payment contract?

A concurrent review Signup and view all the answers

What pays a fixed amount Per Member Per Month to a provider?

Capitation Signup and view all the answers

What is the most common in relationships between primary care physicians and managed care plans?

Capitation Signup and view all the answers

_________ at 50% of the normal per-procedure fee.

Secondary procedure Signup and view all the answers

What is the average level of severity of conditions of patients known as?

case mix index Signup and view all the answers

What are examples of risk-based contracts?

MSSP ACOs and the Quality Payment Program Signup and view all the answers

___ contracts overlay a conventional payment methodology with a retrospective settlement mechanism.

risk based Signup and view all the answers

_________ the payer and the provider share financially in both the risks and rewards of healthcare services.

risk based contract Signup and view all the answers

From the perspective of the medical group, what poses the least financial risk?

charge based payment Signup and view all the answers

What is the least to greatest risk to healthcare providers?

least risk - charge based payment; greatest risk - Capitation Signup and view all the answers

What represents the greatest and least financial risk for hospitals?

greatest risk - cost based payment; least risk - charge based payment Signup and view all the answers

What is a payment based on a pre-determined amount for a specified service?

case rate Signup and view all the answers

What is payment based on billed charges or a percentage discount of charges?

charge based Signup and view all the answers

What is payment based on a patient's diagnosis?

DRG Signup and view all the answers

What is payment based on a fixed amount per day?

per diem Signup and view all the answers

Ambulatory Payment Classification (APC) and Resource-Based Relative Value Scale (RBRVS) are both approaches to which type of payment?

per procedure payment Signup and view all the answers

Study Notes

Healthcare Payment Terminology

Deductible: Pre-determined amount a patient pays before insurance covers services.
Coinsurance: Percentage of the insurance payment that the patient also pays.
Copayment: Fixed amount paid by the patient at each service time.
Out-of-pocket payment: Payment for non-covered services and amounts exceeded by out-of-network providers.
Cost to the patient: Total patient expenses for healthcare, including deductibles, copayments, and balance-billed amounts not covered by insurance.
Costs to the provider: Both direct and indirect expenses incurred for delivering healthcare services.
Cost to the health plan/insurer: Amount reimbursed to the provider for services rendered.
Cost to the employer: Expenses incurred related to employee healthcare benefits, including premiums and claims.
Charge: Dollar amount set by a provider before negotiations that may differ from the paid amount.
Price: Total expected payment for healthcare services from various payers.

Healthcare Providers and Plans

Health Plan/Payer: Organization negotiating rates, collecting premiums or tax revenues, and processing health claims.
Provider: Entity or individual delivering healthcare services.
Balance Billing: Practice of billing patients for charges exceeding the insurance payment—prohibited for in-network but common for out-of-network providers.

Payment Systems in Healthcare

Price Transparency: Clear access to healthcare service prices, assisting patients in making informed choices.
Value: Quality of healthcare services measured against total price paid by purchasers.
Revenue Cycle: Flow of money between patients, insurers, and healthcare providers.
Billing and Collection: Critical function managing resources between healthcare facilities and insurers.
Reimbursement: Older term for insurance payment process, now commonly referred to simply as "payment."

Payment Mechanisms

Fee-for-service: Charge-based system where providers are paid based on the services rendered.
Cost-based payment: Rarely used now, mainly for critical access hospitals—payment based on actual service costs.
Prospective Payment Systems (PPS): Fixed payments based on diagnosis or treatment procedures, introduced to control rising healthcare costs.
Diagnosis Related Group (DRG): Fixed rate payment system based on the patient's diagnosis; flat rate adjusted for severity and resources.
Per Diem Payment System: Fixed daily rate for care, primarily in long-term care facilities; incentivizes longer patient stays.
Capitation: Fixed payment per patient per month for comprehensive services, common in primary care and managed care settings.
Bundled Payment: Single payment covering a range of services provided by multiple providers during an episode of care.

Risk-based Payment Models

Risk-based contract: Arrangement where providers share in the financial risks and rewards, promoting cost management.
Shared Savings Programs: Incentivizes providers to reduce healthcare costs while maintaining quality care.
Value-based payment: Aiming to align providers' incentives toward improving care quality rather than volume.

Coding and Claims Management

Coding: Process of assigning codes to medical records to describe diagnoses and procedures.
Errors in claims: Common mistakes include duplicate charges or incorrect coding, which can lead to claim denials.
Concurrent review: Collaboration between facility staff and health plans for effective patient stay justification.

Payment Security and Incentives

Utilization Management Program: Essential for controlling costs under per-procedure payment models to ensure medical necessity in services rendered.### Claims and Payment Processing
Claims for payment are recorded in the ANSI 837 Healthcare Claim Format, known as the 837 record.
Remittance advice detailing payment decisions is sent via the ANSI 835 Healthcare Claim Payment/Advice, referred to as the 835 record.
Claim logging occurs when a health plan acknowledges receipt of a claim, typically through electronic acknowledgment.
Claims adjudication is the process steps required by a health plan to process claims for payment.
Payment processing steps include claim logging, eligibility verification, adjudication, and remittance issuance.

Revenue Cycle Management

The combined activities pre-visit, during-visit, and post-visit are collectively known as the revenue cycle.
The adjudication cycle is the process involved for a payer's clean review of claims.

Compliance and Regulations

Fraud is the intentional deception or misrepresentation of facts for gain and is subject to criminal penalties with a high burden of proof.
Abuse refers to unintentional actions inconsistent with accepted practices and carries civil monetary penalties with a lower burden of proof.
The goal of compliance programs is to prevent fraud and abuse within healthcare practices.

Legal Framework

The False Claims Act allows the federal government to recover damages up to $11,000 for each false claim.
Whistleblowers report violations of laws, gross mismanagement, or dangers to public health and safety.
HIPAA protects patient health information, requiring patient authorization for certain disclosures and limiting information sharing to the minimum necessary.
Stark I and II prohibit self-referrals by physicians for health services with entities they have a financial relationship with.
The Anti-Kickback Statute criminalizes the exchange of remuneration to induce referrals.

Financial Management

Cash is a primary source of working capital management.
Working capital is the surplus of cash and near-cash items (like accounts receivable) over current obligations, which is crucial for daily operations.
Prairie Family Care faces potential risks from increased service utilization if they accept capitation from Premier Health Plan.
Charles Medical Center's priority in forming a Medicare ACO is developing information systems for effective operation.

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Description

Test your knowledge with these flashcards for CHFP Module 1 Certification. The cards cover key insurance terminology such as deductible, coinsurance, and copayment. Perfect for anyone preparing for their certification in healthcare finance.