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Page 1 When does a hospital add ambulance charges to the Medicare inpatient claim? - ANSWER- If the patient requires ambulance transportation to a skilled nursing facility How should a provider resolve a late-charge credit posted after an account is billed? - ANSWER- Posta late-charge adjustment to the account an increase in the dollars aged greater than 90 days from date of service indicate what about accounts - ANSWER- They are not being processed in a timely manner What is an advantage of a preregistration program? - ANSWER- It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - ANSWER- Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - ANSWER- Scheduling, insurance verification, discharge processing, and payment of point-of- service receipts What statement applics to the scheduled outpatient? - ANSWER- The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - ANSWER- Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount What type of patient status is used to evaluate the patient's need for inpatient care? - ANSWER- Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - ANSWER- Medically necessary inpatient hospital services for at least 3 consecutive days before the skilled nursing care admission When is the word "SAME" entered on the CMS 1500 billing form in Field 0$? - ANSWER- When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - ANS WER- Unscheduled patients If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - ANSWER- Neither enrolled not entitled to benefits Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what? - ANSWER- Disclosure rules for consumer eredit sales and consumer loans What is a principal diagnosis? - ANSWER- Primary reason for the patient's admission Collecting patient liability dollars after service leads to what? - ANSWER- Lower accounts receivable levels What is the daily out-of-pocket amount for cach lifetime reserve day used? - ANSWER- 50% of the current deductible amount What service provided to a Medicare beneficiary ina rural health clinic (RHC) is not billable as an RHC services? - ANSWER- Inpatient care What code indicates the disposition of the patient at the conclusion of service? - ANSWER- Patient discharge status code What arc hospitals required to do for Medicare credit balance accounts? - ANSWER- They result in lost reimbursement and additional cost to collect When an undue delay of payment results from a dispute between the patient and the third party payer, who is responsible for payment? - ANSWER- Patient Medicare What results from a denied claim? - ANSWER- The provider incurs rework and appeal costs Why does the financial counselor need pricing for services? - ANSWER- To calculate the patient's financial responsibility What type of provider bills third-party payers using CMS 1500 form - ANSWER- Hospital-based mammography centers How are disputes with nongovernmental payers resolved? - ANSWER- Appeal conditions specified in the individual payer's contract The important message from Medicare provides beneficiaries with information concerning what? - ANSWER- Right to appeal a discharge decision ifthe patient disagrees with the services Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - ANSWER- To improve access to quality healthcare Tfa patient remains an inpatient ofan SNF (skilled nursing facility for more than 30 days, what is the SNF permitted to do? - ANSWER- Submit interim bills to the Medicare program. 90. MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - ANSWER- 120 days passes, but the claim then be withdrawn from the liability carrier What data are required to establish a new MPI entry? - ANSWER- The patient's full legal name, date of birth, and sex What should the provider do if both of the paticnt's insurance plans pay as primary? - ANSWER- Determine the correct payer and notify the incorrect payer of the processing error What do EMTALA regulations require on-call physicians to do? - ANSWER- Personally appear in the emergency department and attend to the patient within a reasonable time Page 5 At the end ofeach shift, what must happen to cash, checks, and credit card transaction documents? - ANS WER- They must be balanced What will cause a CMS 1500 claim to be rejected? - ANSWER- The provider is billing witha future date of service Under Medicare regulations, which of the following is not included ona valid physician's order for services? - ANSWER- The cost of the test how are HCPCS codes and the appropriate modifiers used? - ANSWER- To report the level 1, 2, or 3 code that correctly describes the service provided Ifa Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - ANSWER- Diagnostic and clinically-related non-diagnostic charges provided on the Tuesday, Wednesday, Thursday, and Friday before admission What is a benefit of pre-registering patient's for service? - ANSWER- Patient arrival processing is expedited, reducing wait times and delays What is a characteristic ofa managed contracting methodology? - ANSWER- Prospectively set rates for inpatient and outpatient services What do the MSP disability rules require? - ANSWER- That the paticnt's spouse's employer must have less than 20 employees in the group health plan what organization originated the concept of insuring prepaid health care services? - ANSWER- Blue Cross and blue Shield What is truc about screening a beneficiary for possible MSP situations? - ANSWER- Itis acceptable to complete the screening form after the patient has completed the registration process and been sent to the service department Tf the patient cannot agree to payment arrangements, what is the next option? - ANSWER- Warn the patient that unpaid accounts are placed with collection agencies for further processing Page 7 What option is an alternative to valid long-term payment plans? - ANSWER- Bank loans What is an advantage of using a collection agency to collect delinquent patient accounts? - ANSWER- Collection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? - ANSWER- revenue codes identify the payer 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 - ANSWER- catastrophic charity What happens when a patient receives non-emergent services from and out-of- network provider? - ANSWER- Patient payment responsibility is higher Every patient who is new to the healthcare provider must be offered what? - ANSWER- A printed copy of the provider's privacy notice How may a collection agency demonstrate its performance? - ANSWER- Calculate the rate of recovery What is true of the information the provider supplies to indicate that an authorization for service has been reecived from the paticnt's primary payer? - ANSWER- It is posted on the remittance advice by the payer What standard claim forms are currently used by the healthcare industry to submit claims to third-party payers? - ANSWER- The UB-04 and the CMS 1500 Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information? - ANSWER- Obtain the required demographic and insurance information before services are rendered what protocol was developed through the Patient Friendly Billing Project? - ANSWER- Provide information using language that is easily understood by the average reader What technique is acceptable way to complete the MSP screening fora facility situation? - ANSWER- Ask if the patient's current services was accident related What is a valid reason for a payer to delay a claim? - ANSWER- Failure to complete authorization requirements IF outpatient diagnostic services are provided within three days of the admission ofa Medicare beneliciary to an [PPS (Inpatient Prospective Payment System) hospital, what must happen to these charges - ANSWER- They must be combined with the inpatient bill and paid under the MS-DRG system What do large adjustments require? - ANSWER- Manager-level approval What items are valid identifiers to establish a patient's identification? - ANSWER- Photo identification, date of birth, and social security number What must a provider do to qualify an account as a Medicare bad debts? - ANSWER- Pursue the account for 120 days and then refer it to an outside collection agency What restriction does a managed care plan place on locations that must be used ifthe plan is to pay for the services provided? - ANSWER- Site-of-service limitation What is an example ofan outcome of the Patient Friendly Billing Project? - ANSWER- Redesigned patient billing statements using patient-friendly language What statement describes the APC (Ambulatory payment classification) system? - ANSWER- APC rates are calculated on a national basis and are wage-adjusted by geographic region What is a benefit of insurance verification? - ANSWER- Pre-certification or pre- authorization requirements are confirmed What is an effective tool to help staff collect payments at the time of service? - ANSWER- Develop scripts for the process of requesting payments What is a benefit of electronic claims processing? - ANSWER- Providers can electronically view patient's eligibility What does Medicare Part D provide coverage for? - ANSWER- Prescription drugs First dollar coverage - ANSWER- A healthcare insurance policy that has no deductible and covers the first dollar ofan insured's expenses Gatekeeping - ANSWER- A concept wherein the primary care physician provides all primary patient care and coordinates all diagnostic testing and specialty referrals required for a patient's medical care Health plan - ANSWER- an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - ANS WER- negotiated healthcare coverage within a framework of fec schedules, limitations, and exclusions that is offered by insurance companics or benevolent associations Medically necessary - ANS WER- Healthcare services that are required to preserve or maintain a person's health status in accordance with medical practice standards Out-of-arca bencfits - ANSWER- healthcare plan coverage allowed to covered persons for emergency situations outside of the prescribed geographic area of the HMO Out-of-pocket payments - ANSWER- Cash payments made by the insured for services not covered by the health insurance plan Pre-admission review - ANS WER- the practice of reviewing requests for inpatient admission before the paticnt is admitted to ensure that the admission is medically necesary Pre-existing condition limitation - ANSWER- A restriction on payments for charges directly resulting from a pre-cxisting health conditions Same-day admission - ANSWER- A cost containment practice that reduces a surgical patient's inpatient stay by requiring that pre-procedure testing and preparation are completed on an outpatient basis and the patient is admitted the same day as the procedure Sclf-insured - ANSWER- Large employers who assume direct responsibility or risk for paying employees' healthcare without purchasing health insurance Subrogation - ANSWER- Seeking, by legal or administrative means, reimbursement from another party that is primarily responsible for a patient's medical expenses Subscriber - ANS WER- An employer, a union, or an association that contracts with an insurance company for the healthcare plan it offers to eligible employees Sub- specialist - ANSWER- A healthcare professional who is recognized to have expertise ina specialty of medicine or surgery Third-part administrator (TPA) - ANSWER- Provides services to employers or insurance companies for utilization review, claims payment and benefit design Third-party reimbursement - ANSWER- A general term used for the healthcare benefit payments - used to identify that for benefit plans there are three parties in the transaction Usual, customary, and reasonable (UCR) - ANSWER- Health 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 Utilization review - ANSWER- Review conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Charge - ANSWER- The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid Cost - ANSWER- The definition of cost varies by party incurring the expense Price - ANSWER- the total amount a provider expects to be paid by payers and patients for healthcare services Out of pocket payment - ANSWER- The portion of the total payment for medical services and treatment for which the patient is responsible, including copayments, coinsurance, and deductibles Price transparency - ANSWER- In 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 valuc Value- ANSWER- The quality ofa healthcare service in relation to the total price paid for the service by care purchasers What arcas does the code of conduct typically focus on? - ANSWER- Human resources. Privacy/confidentiality. Quality of carc. Billing/coding. Conflicts of interest. Laws/regulations FERA - ANSWER- Fraud Enforcement and Recovery act ESRD - ANSWER- End-stage renal disease. The patient has permanent kidney failure, is covered by a GHP, and has not yet completed the 30-month coordination period What is the purpose of a compliance program? - ANSWER- Mitigate potential fraud and abuse in the industry-specific key risk areas What is important about an effective corporate compliance program? - ANSWER- A program that embodies many elements to create a program that is transparent, clearly articulated and emphasized at all employee levels as a seriously held personal and organizational responsibility, one that relies on full communication inside and outside the organization What is a CCO- ANSWER- Chief compliance officer - they typically report directly to the board of directors/trustees as well as the chief executive officer, and has limited responsibilitics for other operational aspects of the organization What are the situations where another payer may be completely responsible for payment? - ANSWER- Work-related accidents, black lung program services, patient is enrolled in Medicare Advantage, Federal grant programs 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. - ANSWER- TRUE The OIG has issued compliance guidance/model compliance plans for all of the following entitics: - ANSWER- hospices. physician practices. ambulance providers Providers who are found to be in violation of CMS regulations are subject to: - ANSWER- Corporate integrity agreements What MSP situation requires LGHP - ANSWER- Disability The disadvantages of outsourcing include all of the following EXCEPT: a) The impact of customer service or patient relations b) The impact of loss of direct control ofaccounts receivable services c) Increased costs due to vendor ineffectiveness d) Reduced internal staffing costs and a reliance on outsourced staff- ANSWER- D The Medicare fee-for service appeal process for both beneficiaries and providers includes all of the following levels EXCEPT: a) Medical necessity review by an independent physician's panel b) Judicial review by a federal district court c) Redetermination by the company that handles claims for Medicare d) Review by the Medicare Appeals Council (Appeals Council) - ANSWER- B Business ethics, or organizational ethics represent: a) The principles and standards by which organizations operate b) Regulations that must be followed by law c) Definitions of appropriate customer service d) The code of acceptable conduct - ANSWER- A Across all care settings, ifa patient consents to a financial discussion during a medical encounter to expedite discharge, the HFMA best practice is to: a) Make sure that the attending staff can answer questions and assist in obtaining required patient financial data Have a patient financial responsibilities kit ready for the patient, containing all of the required registration forms and instructions c) Support that choice, providing that the discussion does not interfere with paticnt care or disrupt paticnt flow d) Decline such request as finance discussions can disrupt patient care and patient flow - ANSWER- C Acomprchensive "Compliance Program" is defined as a) Annual legal audit and review for adherence to regulations b) Educating staffon regulations c) Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met d) The development of operational policies that correspond to regulations - ANSWER- C Case Management requires that a case manager be assigned a) To patients of any physician requesting case management b) Toasclect patient group c) To every patient d) To specific cases designated by third party contractual agreement - ANSWER- B Pricing transparency is defined as readily available information on the price of healthcare services, that together with other information, help define the value of those services and enable consumers to a) Identify, compare, and choose providers that offer the desired level of value b) Customize health care with a personally chosen mix of providers c) Negotiate the cost of health plan premiums d) Verily the cost of individual clinicians - ANSWER- A Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons based ona monthly fee is known as aa) MSO HMO b) Maintaining routine contact with the health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of: a) Patient Accounts b) Managed Care Contract Staff c) HIMstaff d) Case Management - ANSWER- D What is required for the UB-04/837-I, used by Rural Health Clinics to generate payment from Medicare? a) Revenue codes b) Correct Part A and B procedural codes c) The CMS 1500 Part B attachment d) Medical necessity documentation - ANSWER- A Before classifying and subsequently writing off an account to financial assistance or bad debt, the hospital must establish policy, define appropriate criteria, implement procedures for identifying and processing accounts: a) Monitor compliance b) Have the account triaged for any partial payment possibilities c) Assist in arranging for a commercial bank loan d) Obtain the patients income tax statements from the prior 2 years - ANSWER- A For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions: a) Are optional b) Should take place between the patient or guarantor and properly trained provider representatives c) May take place between the patient and discharge planning d) Are focused on verifying required third-party payer information - ANSWER-B The purpose ofa financial reportis to: a) Provide a public record, ifreqluested b) Present financial information to decision makers c) Prepare tax documents d) Monitor expenses - ANSWER- B Which statement is an EMTALA (Emergency Medical Treatment and Active Labor Act) violation? a) Registration sta{{may routinely contact managed are plans for prior authorizations before the patient is seen by the on-duty physician b) Initial registration activitics may occur so long as these activitics do not delay treatment or suggest that treatment with not be provided to uninsured individuals c) Co-payments may be collected at the time of service onee the medical screening and stabilization activities are completed d) Signage must be posted where it can be easily seen and read by patients - ANSWER- A A claim is denied for the following reasons, EXCEPT: a) The health plan cannot identify the subscriber b) The frequency of service was outside the coverage timeline c) The submitted claim does not have the physicians signature d) The subscriber was not enrolled at the time of service - ANSWER- C Any provider that has filed a timely cost report may appeal an adverse final decision reecived from the Medicare Administrative Contractor (MAC). This appeal may be filed with a) A court appointed federal mediator b) The Department of Health and Human Services Provider Relations Division c) The Office of the Inspector General d) The Provider Reimbursement Review Board - ANSWER- D Charges, as the most appropriate measurement of utilization, cnables a) Generation of timely and accurate billing b) Managing of expense budgets ce) Accuracy of expense and cost capture d) Effective HIM planning - ANSWER- ??? Number 24??? 
