CRCR Exam Prep Flashcards 2021

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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?

Holding staff accountable for customer service during performance reviews Signup and view all the answers

What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do?

Inform a Medicare beneficiary that Medicare may not pay for the order or service Signup and view all the answers

What type of account adjustment results from the patient's unwillingness to pay for a self-pay balance?

Bad debt adjustment Signup and view all the answers

What is the initial hospice benefit?

Two 90-day periods and an unlimited number of subsequent periods Signup and view all the answers

When does a hospital add ambulance charges to the Medicare inpatient claim?

If the patient requires ambulance transportation to a skilled nursing facility Signup and view all the answers

How should a provider resolve a late-charge credit posted after an account is billed?

Post a late-charge adjustment to the account Signup and view all the answers

What does an increase in dollars aged greater than 90 days from the date of service indicate about accounts?

They are not being processed in a timely manner Signup and view all the answers

What is an advantage of a preregistration program?

It reduces processing times at the time of service Signup and view all the answers

What are the two statutory exclusions from hospice coverage?

Medically unnecessary services and custodial care Signup and view all the answers

What core financial activities are resolved within patient access?

Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts Signup and view all the answers

What statement applies to the scheduled outpatient?

The services do not involve an overnight stay Signup and view all the answers

How is a mis-posted contractual allowance resolved?

Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount Signup and view all the answers

What type of patient status is used to evaluate the patient's need for inpatient care?

Observation Signup and view all the answers

Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what?

Medically necessary inpatient hospital services for at least 3 consecutive days before the skilled nursing care admission Signup and view all the answers

When is the word 'SAME' entered on the CMS 1500 billing form in Field 0$?

When the patient is the insured Signup and view all the answers

What are non-emergency patients who come for service without prior notification to the provider called?

Unscheduled patients Signup and view all the answers

If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse?

Neither enrolled nor entitled to benefits Signup and view all the answers

Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what?

Disclosure rules for consumer credit sales and consumer loans Signup and view all the answers

What is a principal diagnosis?

Primary reason for the patient's admission Signup and view all the answers

Collecting patient liability dollars after service leads to what?

Lower accounts receivable levels Signup and view all the answers

What is the daily out-of-pocket amount for each lifetime reserve day used?

50% of the current deductible amount Signup and view all the answers

What service provided to a Medicare beneficiary in a rural health clinic (RHC) is not billable as an RHC service?

Inpatient care Signup and view all the answers

What code indicates the disposition of the patient at the conclusion of service?

Patient discharge status code Signup and view all the answers

What are hospitals required to do for Medicare credit balance accounts?

They result in lost reimbursement and additional cost to collect Signup and view all the answers

When an undue delay of payment results from a dispute between the patient and the third party payer, who is responsible for payment?

Patient Signup and view all the answers

Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include:

A valid CPT or HCPCS code Signup and view all the answers

With advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what?

Access their information and perform functions online Signup and view all the answers

What date is required on all CMS 1500 claim forms?

Onset date of current illness Signup and view all the answers

What does scheduling allow provider staff to do?

Review appropriateness of the service request Signup and view all the answers

What code is used to report the provider's most common semiprivate room rate?

Condition code Signup and view all the answers

Regulations and requirements for coding accountable care organizations, which allows providers to begin creating these organizations, were finalized in:

2012 Signup and view all the answers

What is a primary responsibility of the Recover Audit Contractor?

To correctly identify proper payments for Medicare Part A & B claims Signup and view all the answers

How must providers handle credit balances?

Comply with state statutes concerning reporting credit balances Signup and view all the answers

Insurance verification results in what?

The accurate identification of the patient's eligibility and benefits Signup and view all the answers

What form is used to bill Medicare for rural health clinics?

CMS 1500 Signup and view all the answers

What activities are completed when a scheduled pre-registered patient arrives for service?

Registering the patient and directing the patient to the service area Signup and view all the answers

In addition to being supported by information found in the patient's chart, a CMS 1500 claim must be coded using what?

HCPCS (Healthcare Common Procedure Coding System) Signup and view all the answers

What results from a denied claim?

The provider incurs rework and appeal costs Signup and view all the answers

Why does the financial counselor need pricing for services?

To calculate the patient's financial responsibility Signup and view all the answers

What type of provider bills third-party payers using the CMS 1500 form?

Hospital-based mammography centers Signup and view all the answers

How are disputes with nongovernmental payers resolved?

Appeal conditions specified in the individual payer's contract Signup and view all the answers

The important message from Medicare provides beneficiaries with information concerning what?

Right to appeal a discharge decision if the patient disagrees with the services Signup and view all the answers

Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members?

To improve access to quality healthcare Signup and view all the answers

If a patient remains an inpatient of an SNF (skilled nursing facility) for more than 30 days, what is the SNF permitted to do?

Submit interim bills to the Medicare program Signup and view all the answers

MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens?

120 days pass, but the claim can then be withdrawn from the liability carrier Signup and view all the answers

What data are required to establish a new MPI entry?

The patient's full legal name, date of birth, and sex Signup and view all the answers

What should the provider do if both of the patient's insurance plans pay as primary?

Determine the correct payer and notify the incorrect payer of the processing error Signup and view all the answers

What do EMTALA regulations require on-call physicians to do?

Personally appear in the emergency department and attend to the patient within a reasonable time Signup and view all the answers

At the end of each shift, what must happen to cash, checks, and credit card transaction documents?

They must be balanced Signup and view all the answers

What will cause a CMS 1500 claim to be rejected?

The provider is billing with a future date of service Signup and view all the answers

Under Medicare regulations, which of the following is not included on a valid physician's order for services?

The cost of the test Signup and view all the answers

How are HCPCS codes and the appropriate modifiers used?

To report the level 1, 2, or 3 code that correctly describes the service provided Signup and view all the answers

If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule?

Diagnostic and clinically-related non-diagnostic charges provided on the Tuesday, Wednesday, Thursday, and Friday before admission Signup and view all the answers

What is a benefit of pre-registering patients for service?

Patient arrival processing is expedited, reducing wait times and delays Signup and view all the answers

What is a characteristic of a managed contracting methodology?

Prospectively set rates for inpatient and outpatient services Signup and view all the answers

What do the MSP disability rules require?

That the patient's spouse's employer must have less than 20 employees in the group health plan Signup and view all the answers

What organization originated the concept of insuring prepaid health care services?

Blue Cross and Blue Shield Signup and view all the answers

What is true about screening a beneficiary for possible MSP situations?

It is acceptable to complete the screening form after the patient has completed the registration process and been sent to the service department Signup and view all the answers

If the patient cannot agree to payment arrangements, what is the next option?

Warn the patient that unpaid accounts are placed with collection agencies for further processing Signup and view all the answers

In service lines such as cardiology or orthopedics, what does the case-rate payment methodology allow providers to do?

Receive a fixed amount for specific procedures Signup and view all the answers

What will comprehensive patient access processing accomplish?

Minimize the need for follow-up on insurance accounts Signup and view all the answers

Through what document does a hospital establish compliance standards?

Code of conduct Signup and view all the answers

How does utilization review staff use correct insurance information?

To obtain approval for inpatient days and coordinate services Signup and view all the answers

When is it not appropriate to use observation status?

As a substitute for an inpatient admission Signup and view all the answers

What is a serious consequence of misidentifying a patient in the MPI?

The services will be documented in the wrong record Signup and view all the answers

When a patient reports directly to a clinical department for service, what will the clinical department staff do?

Redirect the patient to the patient access department for registration Signup and view all the answers

What process can be used to shorten claim turnaround time?

Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail Signup and view all the answers

How are patient reminder calls used?

To make sure the patient follows the prep instructions and arrives at the scheduled time for service Signup and view all the answers

If a patient declares a straight bankruptcy, what must the provider do?

Write off the account to the contractual adjustment account Signup and view all the answers

According to the Department of Health and Human Services guidelines, what is NOT considered income?

Sale of property, house, or car Signup and view all the answers

The situation where neither the patient nor spouse is employed is described to the patient using:

A condition code Signup and view all the answers

What option is an alternative to valid long-term payment plans?

Bank loans Signup and view all the answers

What is an advantage of using a collection agency to collect delinquent patient accounts?

Collection agencies collect accounts faster than hospitals do Signup and view all the answers

What statement DOES NOT apply to revenue codes?

Revenue codes identify the payer Signup and view all the answers

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?

Catastrophic charity Signup and view all the answers

What happens when a patient receives non-emergent services from an out-of-network provider?

Patient payment responsibility is higher Signup and view all the answers

Every patient who is new to the healthcare provider must be offered what?

A printed copy of the provider's privacy notice Signup and view all the answers

How may a collection agency demonstrate its performance?

Calculate the rate of recovery Signup and view all the answers

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?

It is posted on the remittance advice by the payer Signup and view all the answers

What standard claim forms are currently used by the healthcare industry to submit claims to third-party payers?

The UB-04 and the CMS 1500 Signup and view all the answers

Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information?

Obtain the required demographic and insurance information before services are rendered Signup and view all the answers

What protocol was developed through the Patient Friendly Billing Project?

Provide information using language that is easily understood by the average reader Signup and view all the answers

What technique is an acceptable way to complete the MSP screening for a facility situation?

Ask if the patient's current services were accident-related Signup and view all the answers

What is a valid reason for a payer to delay a claim?

Failure to complete authorization requirements Signup and view all the answers

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?

They must be combined with the inpatient bill and paid under the MS-DRG system Signup and view all the answers

What do large adjustments require?

Manager-level approval Signup and view all the answers

What items are valid identifiers to establish a patient's identification?

Photo identification, date of birth, and social security number Signup and view all the answers

What must a provider do to qualify an account as a Medicare bad debt?

Pursue the account for 120 days and then refer it to an outside collection agency Signup and view all the answers

What restriction does a managed care plan place on locations that must be used if the plan is to pay for the services provided?

Site-of-service limitation Signup and view all the answers

What is an example of an outcome of the Patient Friendly Billing Project?

Redesigned patient billing statements using patient-friendly language Signup and view all the answers

What statement describes the APC (Ambulatory Payment Classification) system?

APC rates are calculated on a national basis and are wage-adjusted by geographic region Signup and view all the answers

What is a benefit of insurance verification?

Pre-certification or pre-authorization requirements are confirmed Signup and view all the answers

What is an effective tool to help staff collect payments at the time of service?

Develop scripts for the process of requesting payments Signup and view all the answers

What is a benefit of electronic claims processing?

Providers can electronically view patient's eligibility Signup and view all the answers

What does Medicare Part D provide coverage for?

Prescription drugs Signup and view all the answers

What are some core elements of a board-approved financial policy?

Charity care, payment methods, and installment payment guidelines Signup and view all the answers

What circumstance would result in an incorrect nightly room charge?

If the patient's discharge, ordered for tomorrow, has not been charted Signup and view all the answers

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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Description

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.