Questions and Answers
What are collection agency fees based on?
A percentage of dollars collected
Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule?
Birthday
In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers?
Case rates
What customer service improvements might improve the patient accounts department?
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What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do?
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What type of account adjustment results from the patient's unwillingness to pay for a self-pay balance?
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What is the initial hospice benefit?
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When does a hospital add ambulance charges to the Medicare inpatient claim?
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How should a provider resolve a late-charge credit posted after an account is billed?
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What does an increase in dollars aged greater than 90 days from the date of service indicate about accounts?
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What is an advantage of a preregistration program?
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What are the two statutory exclusions from hospice coverage?
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What core financial activities are resolved within patient access?
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What statement applies to the scheduled outpatient?
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How is a mis-posted contractual allowance resolved?
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What type of patient status is used to evaluate the patient's need for inpatient care?
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Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what?
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When is the word 'SAME' entered on the CMS 1500 billing form in Field 0$?
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What are non-emergency patients who come for service without prior notification to the provider called?
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If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse?
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Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what?
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What is a principal diagnosis?
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Collecting patient liability dollars after service leads to what?
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What is the daily out-of-pocket amount for each lifetime reserve day used?
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What service provided to a Medicare beneficiary in a rural health clinic (RHC) is not billable as an RHC service?
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What code indicates the disposition of the patient at the conclusion of service?
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What are hospitals required to do for Medicare credit balance accounts?
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When an undue delay of payment results from a dispute between the patient and the third party payer, who is responsible for payment?
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Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include:
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With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what?
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What date is required on all CMS 1500 claim forms?
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What does scheduling allow provider staff to do?
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What code is used to report the provider's most common semiprivate room rate?
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Regulations and requirements for coding accountable care organizations, which allows providers to begin creating these organizations, were finalized in:
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What is a primary responsibility of the Recover Audit Contractor?
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How must providers handle credit balances?
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Insurance verification results in what?
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What form is used to bill Medicare for rural health clinics?
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What activities are completed when a scheduled pre-registered patient arrives for service?
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In addition to being supported by information found in the patient's chart, a CMS 1500 claim must be coded using what?
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What results from a denied claim?
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Why does the financial counselor need pricing for services?
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What type of provider bills third-party payers using the CMS 1500 form?
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How are disputes with nongovernmental payers resolved?
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The important message from Medicare provides beneficiaries with information concerning what?
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Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members?
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If a patient remains an inpatient of an SNF (skilled nursing facility) for more than 30 days, what is the SNF permitted to do?
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MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens?
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What data are required to establish a new MPI entry?
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What should the provider do if both of the patient's insurance plans pay as primary?
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What do EMTALA regulations require on-call physicians to do?
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At the end of each shift, what must happen to cash, checks, and credit card transaction documents?
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What will cause a CMS 1500 claim to be rejected?
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Under Medicare regulations, which of the following is not included on a valid physician's order for services?
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How are HCPCS codes and the appropriate modifiers used?
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If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule?
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What is a benefit of pre-registering patients for service?
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What is a characteristic of a managed contracting methodology?
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What do the MSP disability rules require?
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What organization originated the concept of insuring prepaid health care services?
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What is true about screening a beneficiary for possible MSP situations?
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If the patient cannot agree to payment arrangements, what is the next option?
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In service lines such as cardiology or orthopedics, what does the case-rate payment methodology allow providers to do?
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What will comprehensive patient access processing accomplish?
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Through what document does a hospital establish compliance standards?
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How does utilization review staff use correct insurance information?
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When is it not appropriate to use observation status?
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What is a serious consequence of misidentifying a patient in the MPI?
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When a patient reports directly to a clinical department for service, what will the clinical department staff do?
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What process can be used to shorten claim turnaround time?
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How are patient reminder calls used?
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If a patient declares a straight bankruptcy, what must the provider do?
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According to the Department of Health and Human Services guidelines, what is NOT considered income?
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The situation where neither the patient nor spouse is employed is described to the patient using:
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What option is an alternative to valid long-term payment plans?
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What is an advantage of using a collection agency to collect delinquent patient accounts?
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What statement DOES NOT apply to revenue codes?
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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?
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What happens when a patient receives non-emergent services from an out-of-network provider?
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Every patient who is new to the healthcare provider must be offered what?
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How may a collection agency demonstrate its performance?
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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?
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What standard claim forms are currently used by the healthcare industry to submit claims to third-party payers?
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Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information?
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What protocol was developed through the Patient Friendly Billing Project?
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What technique is an acceptable way to complete the MSP screening for a facility situation?
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What is a valid reason for a payer to delay a claim?
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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?
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What do large adjustments require?
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What items are valid identifiers to establish a patient's identification?
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What must a provider do to qualify an account as a Medicare bad debt?
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What restriction does a managed care plan place on locations that must be used if the plan is to pay for the services provided?
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What is an example of an outcome of the Patient Friendly Billing Project?
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What statement describes the APC (Ambulatory Payment Classification) system?
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What is a benefit of insurance verification?
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What is an effective tool to help staff collect payments at the time of service?
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What is a benefit of electronic claims processing?
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What does Medicare Part D provide coverage for?
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What are some core elements of a board-approved financial policy?
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What circumstance would result in an incorrect nightly room charge?
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Study Notes
Collection Agency Fees
- Collection agency fees are based on a percentage of dollars collected.
Self-funded Benefit Plans
- Self-funded plans may use the "gender rule" or the "birthday rule" for coordinating benefits.
Payment Methodology
- Case rates involve negotiated lump sum or bundled payments between the payer and providers.
Customer Service Improvements
- Accountability for customer service during performance reviews can enhance the patient accounts department.
Advance Beneficiary Notice of Non-coverage (ABN)
- An ABN informs Medicare beneficiaries that Medicare may not cover a particular service or order.
Account Adjustments
- A patient's unwillingness to pay self-pay balances results in bad debt adjustments.
Hospice Benefits
- The initial hospice benefit consists of two 90-day periods and unlimited subsequent periods.
Medicare Claims and Ambulance Charges
- Hospitals add ambulance charges to Medicare inpatient claims when transporting patients to skilled nursing facilities.
Late-charge Credits
- To resolve late-charge credits on billed accounts, post a late-charge adjustment.
Aged Accounts Receivable
- A rise in amounts aged over 90 days indicates accounts are not being processed promptly.
Preregistration Programs
- Preregistration programs effectively reduce processing times at service by pre-arranging patient details.
Hospice Coverage Exclusions
- Medically unnecessary services and custodial care are excluded from hospice coverage.
Patient Access Financial Activities
- Core financial activities include scheduling, insurance verification, discharge processing, and payment collection.
Scheduled Outpatient Services
- Scheduled outpatient services do not require an overnight stay.
Contractual Allowance Mis-posting
- Resolving mis-posted contractual allowances involves comparing reimbursement rates with contract details.
Inpatient Care Evaluation
- Observation status is used to assess a patient's need for inpatient care.
Medicare Skilled Nursing Care Rules
- Medicare requires a beneficiary to have at least 3 consecutive days of medically necessary inpatient hospital services before skilled nursing admission.
CMS 1500 Billing Form
- The term "SAME" is used on the CMS 1500 form when the patient is also the insured.
Unscheduled Patients
- Non-emergency patients arriving without prior notice to providers are classified as unscheduled patients.
Insurance Verification and Subscriber Status
- If a single-policy verification reveals a subscriber, the spouse is neither enrolled nor entitled to benefits.
Truth in Lending Act
- Regulation Z establishes disclosure rules for consumer credit sales and loans.
Principal Diagnosis Definition
- The principal diagnosis denotes the primary reason for a patient's admission.
Collecting Patient Liability
- Collecting patient liability post-service results in reduced accounts receivable levels.
Lifetime Reserve Day Costs
- The daily out-of-pocket cost for each lifetime reserve day is 50% of the current deductible.
Non-billable Services in RHCs
- Inpatient care provided to a Medicare beneficiary in rural health clinics (RHCs) is non-billable.
Patient Discharge Status
- The patient discharge status code indicates a patient's disposition at the end of service.
Medicare Credit Balance Management
- Hospitals must address Medicare credit balance accounts to prevent lost reimbursements and mitigate collection costs.
Patient Responsibility in Payment Disputes
- When payment disputes arise between patients and third-party payers, the patient remains responsible for payment.
LCD/NCD Testing Orders
- Medicare guidelines stipulate that test orders for LCD or NCD must include valid CPT or HCPCS codes.
Online Revenue Cycle Processes
- Advances in internet security now allow patients to access their information and perform associated functions online.
CMS 1500 Claim Requirements
- The onset date of the current illness is required on all CMS 1500 claim forms.
Scheduling Importance
- Scheduling enables provider staff to review the appropriateness of service requests before patient visits.
Reporting Room Rates
- Condition codes report the provider's standard semiprivate room rates.
ACO Coding Regulations
- Regulations regarding accountable care organizations (ACOs) were finalized in 2012, enabling provider organization creation.
Recover Audit Contractor Role
- The primary responsibility of the Recover Audit Contractor is identifying proper payments for Medicare Part A and B claims.
Managing Credit Balances
- Providers must comply with state laws concerning reporting credit balances.
Benefits of Insurance Verification
- Insurance verification accurately identifies patient eligibility and benefits.
Billing Medicare for Rural Health Clinics
- The CMS 1500 form is utilized for billing Medicare by rural health clinics.
Pre-registered Patient Activities
- Upon arrival, scheduled pre-registered patients go through registration and are directed to service areas.
CMS 1500 Sideline Coding
- Claims on CMS 1500 must be coded using HCPCS (Healthcare Common Procedure Coding System).
Denied Claim Consequences
- Denied claims lead to provider rework and appeal costs.
Pricing for Services
- Financial counselors need service pricing to calculate patients' financial responsibilities accurately.
Providers Billing Third-party Payers
- Hospital-based mammography centers use the CMS 1500 form for billing third-party payers.
Resolving Pay Disputes
- Appeals of disputes with nongovernmental payers follow specified conditions in individual payer contracts.
Medicare Important Message
- The Important Message from Medicare informs beneficiaries of their right to appeal if disagreeing with discharge decisions.
Managed Care Agreements
- Managed care plans form agreements with providers to ensure quality healthcare access for plan members.
Skilled Nursing Facility Billing
- SNFs can submit interim bills to Medicare for patients remaining over 30 days.
Medicare Secondary Payer Rules
- MSP rules allow Medicare billing for liability claims after a 120-day waiting period.
New MPI Entry Data
- Establishing a new Medical Provider Identifier (MPI) requires a patient's full legal name, date of birth, and sex.
Payer Error Notification
- If both insurance plans are primary, determine correct payer and notify the incorrect one.
EMTALA Compliance for On-call Physicians
- On-call physicians must personally attend to patients in the emergency department within a reasonable time under EMTALA regulations.
End of Shift Cash Handling
- Cash, checks, and credit card documents must be balanced at the end of each shift.
CMS 1500 Claim Rejections
- Claims can be rejected if the provider bills for a future date of service.
Valid Physician Order Inclusions
- A valid physician's order does not need to include the cost of the test.
HCPCS Coding and Modifiers
- HCPCS codes and modifiers describe the specific service provided accurately.
Three-day DRG Window Rule
- Charges for outpatient diagnostic services within three days before a Medicare inpatient admission must be combined with the inpatient bill.
Benefits of Pre-registering Patients
- Pre-registering patients expedites arrival processing, minimizing wait times.
Managed Contracting Characteristics
- Managed contracting methodologies feature prospectively set rates for both inpatient and outpatient services.
MSP Disability Rules
- MSP disability rules dictate that a spouse's employer must employ fewer than 20 individuals for coverage.
Prepaid Health Care Concept Origin
- The concept of prepaid health care services originated with Blue Cross and Blue Shield.
MSP Screening Timing
- It’s acceptable to complete MSP screening forms after patient registration and before services.
Bankrupt Accounts Handling
- If a patient declares bankruptcy, the provider should write off the account to the contractual adjustment account.
Non-income Criteria by HHS
- The sale of property, a house, or a car is not considered income per HHS guidelines.
Patient Employment Condition Codes
- Conditions where neither the patient nor spouse is employed are described using condition codes.
Long-term Payment Plan Alternatives
- Bank loans can serve as alternatives to valid long-term payment plans.
Collection Agency Advantages
- Collection agencies efficiently expedite the collection of delinquent accounts compared to hospitals.
Revenue Codes Misconception
- Revenue codes do not identify the payer but categorize services rendered.
Catastrophic Charity Accounts
- When a patient faces overwhelming medical bills not covered by insurance, a catastrophic charity account is created.
Out-of-network Patient Services
- Receiving non-emergency services from out-of-network providers increases the patient's payment responsibility.
New Patient Privacy Notice Requirement
- New patients must receive a printed copy of the provider's privacy notice.
Collection Agency Performance Assessment
- Collection agencies demonstrate effectiveness by calculating recovery rates.
Service Authorization Documentation
- Information confirming service authorization is posted by the payer on remittance advice.
Standard Claim Forms
- The healthcare industry predominantly uses UB-04 and CMS 1500 forms for submitting claims to payers.
Effective Information Collection
- For non-emergency encounters, collecting demographic and insurance information before service is more efficient.
Patient Friendly Billing Protocol
- The Patient Friendly Billing Project promoted providing information in easily understandable language.
Acceptable MSP Screening Techniques
- Facilities may ask if current services are accident-related for completing MSP screenings.
Claim Delay Justifications
- Payers may delay claims due to incomplete authorization requirements.
Outpatient Services and Admittance
- Outpatient diagnostic services provided shortly before a Medicare inpatient admission must be included in the inpatient billing.
Managerial Approval Necessity
- Large adjustments in accounts receivable require approval from management.
Patient Identification Documentation
- Valid patient identifiers include photo ID, date of birth, and social security number.
Medicare Bad Debt Qualifications
- To classify an account as a Medicare bad debt, the provider must pursue the account for 120 days and refer it to collections.
Managed Care Service Limitations
- Managed care plans enforce site-of-service limitations for covered services.
Patient Friendly Billing Outcomes
- An outcome of the Patient Friendly Billing Project includes reformatted billing statements in user-friendly language.
Ambulatory Payment Classification (APC) System
- The APC system calculates rates on a national basis, adjusting for geographic wage
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Prepare for the Certified Revenue Cycle Representative (CRCR) exam with these flashcards. Each card covers key concepts related to revenue cycle management, from collection agency fees to payment methodologies. Perfect for anyone looking to solidify their knowledge in this area.