CRCR Exam Prep Flashcards 2021

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