CRCR Exam Prep, Multiple Choice, Certified Revenue Cycle Representative - Materials from Healthcare Financial Management Association | 2026/2027 | Questions and Correct Answers

1/ 32 CRCR Exam Prep, Multiple Choice, Certified Revenue Cycle Representative - Materials from Healthcare Financial Management Association | 2026/2027 | Questions and Correct Answers 2026/2027 | QUESTIONS & CORRECT ANSWERS | 100% VERIFIED STUDY MATERIAL In what situation(s) should a provider NOT use a modifier? - CPT already indicates 2-4 lesions - CPT indicates multiple extremities 3 multiple choice options What are other names for Three-Day Payment Window? ALL OF THE ABOVE 72-hour rule, DRG window, Three-Day Window, 1 day window or 24-hour rule 3 multiple choice options What happens during the post-service stage? Final coding, preparation and submission of claims, payment processing, balance billing and resolution. 3 multiple choice options What are the below tasks part of? - Educate patients - Coordinate to avoid duplicate patient contacts - Be consistent in key aspects of account resolution - Follow best practices for communication Best practices created by the Medical Debt Task Force 3 multiple choice options Which option is NOT a main HFMA Healthcare Dollars & Sense® revenue cycle initiative? Process Compliance 3 multiple choice options Which option is NOT a continuum of care provider? A. Physician B. Health Plan Contracting C. Hospice D. Skilled Nursing Facility B. Health Plan Contracting 3 multiple choice options What is "implied certification"? When it is implied that a provider met all compliance standards before submitting a claim 3 multiple choice options Which of the following are essential elements of an A. Established compliance standards and procedures. effective compliance program? C. Oversight of personnel by high-level personnel. A. Established compliance standards and procedures. B. Designation of a compliance officer employed within the E. Reasonable methods to achieve compliance with standards, including monitoring Billing Department. systems and hotlines. C. Oversight of personnel by high-level personnel. 3 multiple choice options D. Automatic dismissal of any employee excluded from participation in a federal healthcare program. E. Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines. When was Health Information Technology for Economic and Clinical Health (HITECH) Act signed into law? When did HITECH Act become effective? FEB 17, 2009 3 multiple choice options 2013 3 multiple choice options Annually, the OIG publishes a work plan of compliance issues and objectives that will be focused on throughout the following year. Identify which option is NOT a work plan task mentioned in this course. A. Payments to Physicians for Co-Surgery Procedures B. Denials and Appeals in Medicare Part D C. Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute-Care Transfer Policies D. Standard Unique Employer Identifier D. Standard Unique Employer Identifier 3 multiple choice options 2/ 32 3/ 32 What Plan are the tasks below a part of? - Medicare Payments Made Outside of the Hospice Benefit - Denials and Appeals in Medicare Part C and Part D - Medicare Part B Payments for End-Stage Renal Disease Dialysis Services - Review of Home Health Claims for Services With 5 to 10 Skilled Visits The 2020 OIG Work Plan 3 multiple choice options When was the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act signed into law? JUNE 25 2010 3 multiple choice options What is the Medicare DRG Three-Day Payment Window? All Diagnostic services provided to a Medicare patient by a hospital on the Date of the patient's Inpatient admission or during the 3 calendar days (or in the case of a non-IPPS hospital: 1 calendar day) immediately BEFORE the Date of Admission are REQUIRED to be included on the bill for the IP stay (unless there is no Part A coverage) 3 multiple choice options Do Outpatient Non-Diagnostic Services qualify for separate payments if provided with the Three-Day Payment Window? No What is modifier 59? Used to identify CPTs OTHER THAN E&M services, NOT normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate. 3 multiple choice options What is condition code 51? Code noted on the separate UB-04 OP claim, thus indicating the charge is unrelated to the admission. 3 multiple choice options What kind of hospitals are the following: Cancer treatment facilities, psychiatric, IP rehabilitation, LTC and children's hospitals for examples Non-IPPS hospitals 3 multiple choice options What are the 3 types of medical necessity screenings and noncoverage notifications required in the Medicare program? 1. Advanced Beneficiary Notice of Noncoverage (ABN) for Part B services. 2. SNF ABN for Part A SNF services. 3. HINN - Hospital-Issued Notice of Non-Coverage (Part A) What is Medicare Part B ABN? Used to explain to a Medicare patient that the ordered test or services probably WILL NOT be covered by the Medicare b/c the DX info provided by the Dr. does NOT support the need for these services. ****May also be used for voluntary notifications, in place of the Notice of Exclusion for Medicare Benefits (NEMB). What is the Two-Midnight Rule? Hospital admissions spanning 2 midnights would be considered appropriate for payment under the IPPS rule 3 multiple choice options What are some MSP claims that require additional review by the OIG to ensure compliance? - W/C - Black Lung Program services - Veterans Affairs (VA) services - Federal grant programs - Public Health Service programs (i.e Medicaid) 4/ 32 What are some cases where Medicare is the Secondary Payer? - Working Aged (commercial insurance is Primary) - Accident or other liability (car/tort) - End-Stage Renal Disease (ESRD) - Disability 3 multiple choice options What code must be provided on UB-04 when billing Medicare as Primary for accident or injury? Occurrence Code 05 - ACCIDENT / NO MEDICAL OR LIABILITY COVERAGE 3 multiple choice options How long should a provider wait to bill Medicare after billing liability insurance(s)? 120 days After 120 days, the provider has the option to CX liability claim and bill Medicare. Medicare will process the claim under IPPS rules and recover payment from the liability health plan. 3 multiple choice options What is the Correct Coding Initiative (CCI)? The CCI ensures that the most comprehensive groups of codes, rather than the component parts, are billed. What is a CCI edit? The edits are built in the OP code editor, check for mutually exclusive code pairs. The unit-of-service edits determine the max allowed # of services for each Healthcare Common Procedure Coding System (HCPCS) code. 1 multiple choice option What are examples of Coding initiatives? Modifiers, Exception, and modifiers used for OPPS (Outpatient Prospective Payment System) What is the Beneficiary Notices Initiative (BNI)? Beneficiary Notices Initiative (BNI) details the 9 different types of financial liability notices required under both the traditional Medicare and Medicare Advantage programs. 3 multiple choice options What are modifiers? 2-digit #s OR alpha character that are appended to a CPT/HCPCS code to provide more info about the service without changing its definition or code. Can a service or procedure have both professional and technical component? Yes How many levels of modifiers are used for OPPS (Outpatient Prospective Payment System)? 2 Levels 3 multiple choice options What are Level 1 Modifiers? - Provides info about PERFORMANCE of a procedure - Apply to CPT Codes - Has 2 numbers (ex. Modifier 59) 3 multiple choice options What are Level 2 Modifiers? - Provides info about an ANATOMICAL or about a procedure/service - Apply to HCPCS Codes - Has 2 Letters (ex. Modifier XU, XE) - Has 2 Letter + 1 Number 3 multiple choice options When does Level 2 Modifiers apply to Medicare? When Medicare is the Primary or Secondary payer (append to CPTs). 3 multiple choice options 5/ 32 Why should providers use Level 2 anatomical modifiers? Add specificity to the reporting of CPTs performed on eyelids, fingers, toes, and arteries. How should claim lines be coded if more than one Level 2 Modifiers need to be reported for 1 single code? HCPCS code need to be repeated on another line with the appropriate Level 2 Modifier. Ex. Code 26010 (drainage of finger abscess; simple) done on the left thumb and second finger would be code: 26010FA 26010F1 3 multiple choice options In order to promote the use of correct coding methods on a national basis and prevent payment errors due to improper coding, CMS developed what? The Correct Coding Initiative (CCI) 3 multiple choice options A mother sees a charge on her hospital bill for a circumcision for a newborn girl. This is an example of falsifying medical records to boost reimbursement. True or False False. A physician documents a fictitious epidural in a patient's medical record in an effort to receive additional payments. This an example of miscoding claims. True or False False. Several unauthorized claims are sent to a health plan with the wrong procedure codes. This is an example of overcharging. True or False True. What do business/organizational ethics represent? A. Principles and standards by which organizations operate B. A healthcare provider's practices and principles C. An employee's actions influenced by experiences and value system D. The patient privacy standard within healthcare A. Principles and standards by which organizations operate 3 multiple choice options What is the ACA and when was it signed into law? The Patient Protection and Affordable Care Act, also known as the Affordable Care Act - Signed into law in 2010 What is the ACA's purpose? Reform the healthcare system into a system that rewards greater value, improves the quality of care and increases efficiency in the delivery of services. 3 multiple choice options What provisions did the ACA create? - Improve the quality of care. - Reform the healthcare delivery system. - Encourage pricing transparency and modernized financing systems. - Address the issues of waste, fraud, and abuse. 3 multiple choice options How does the ACA improve quality of care improvements? - Reducing hospital readmissions. - Reducing hospital acquired conditions. - Comprehensive Joint Replacement and Cardiac Services - Improving physician quality reporting. 3 multiple choice options 6/ 32 . What is an Accountable Care Organization (ACO)? Delivery system of physicians, hospitals, and other healthcare providers, who work collaboratively to manage and coordinate the care of a patient population 3 multiple choice options What is the purpose of the below tasks? - Establishing regulations for the development and financing of Accountable Care Organizations (ACOs). - Developing new approaches to payment and delivery systems through the Center for Medicare and Medicaid Innovation (CMSI) Reformations to the healthcare delivery system. 3 multiple choice options What is considered a qualifying ACO? For Medicare, a qualifying ACO requires a minimum of 5,000 beneficiaries. 3 multiple choice options What is Medicare Shared Savings Program (MSSP)? A program that facilitates coordination and cooperation among providers to improve care for Medicare Fee-for-Service (FFS) beneficiaries and reduce unnecessary costs. 3 multiple choice options What is Comprehensive ESRD Care Model? A program designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD). 3 multiple choice options What is the Hospital Readmission Reduction Program? CMS is required to reduce payments to hospitals with excessively high rates of avoidable readmissions for certain conditions. 2 multiple choice options What is Bundled Payment for Care Improvement (BPCI)? Developed by the CMSI to link payments for multiple services beneficiaries receive during an episode of care. Has 4 Models. What is Comprehensive Care for Joint Replacement (CJR) Tests bundled payment and quality measurement for an episode of care associated model? most common IP SX for Medicare beneficiaries: hip and knee replacements (also called lower extremity joint replacements or LEJR). 3 multiple choice options What is Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)? Survey asks recently discharged adult patients 32 QUESTIONS about aspects of their hospital experience that they're uniquely suited to address. Contains: - 21 items = asks "how often" or whether patients experienced a critical aspect of hospital care. - 4 items = direct patients to relevant questions - 5 items = adjust for the mix of patients across hospitals - 2 items = support Congressionally-mandated reports. What is the purpose of Patient Reported Outcome (PRO) - Assess post-operative functional outcomes. Data? - Collect data from the pt's perspective, data that is necessary to finalize and test the specifications of a hospital-level, risk-adjusted patient-reported outcome performance measure (PRO-PM) for primary elective THA/TKA surgical procedures 7/ 32 What is the intended outcome of collaborations made through an ACO delivery system? A. To ensure appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients. B. To create cost-containment provisions to reform the healthcare delivery system. C. To reform the healthcare system into a system that rewards greater value, improves the quality of care and increases efficiency in the delivery of services. D. To provide financial incentives to physicians for reporting quality data to CMS. A. To ensure appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients. 3 multiple choice options What are the governing bodies of financial reports? - The Securities and Exchange Commission (SEC) - The Financial Accounting Standards Board (FASB) - Generally Accepted Accounting Principles (GAAP) What are the most commonly used financial statements? - Balance Sheet - Income Statement - Cash Flow Statement What is accural accounting? Revenue is recorded when it's earned. 3 multiple choice options What is cash accounting? Revenue is recorded when payment's received. 3 multiple choice options What is fund accounting? Record-keeping method to manage categories of net assets to ensure compliance with the restrictions on those funds. What is Gross Revenue? Gross revenue is the total incurred charges entered for all pts for the services they received. What is Net Revenue? REVENUE minus Contractual, Discount or Allowances What change was brought by the implementation of ASC 2 types of adjustment to incurred charges: Explicit price concessions & Implicit price 606? concessions 3 multiple choice options What are Explicit Price Consessions? The discounted contractual agreements between the provider and the payers which specify the payments due from the payers 3 multiple choice options What are Implicit Price Consessions? A concession applied to amounts that are to be paid by patients based on the expected payment results for a specific portfolio of receivables 3 multiple choice options What are price concessions? Contractual Adjustments, Bad Debts, and Charity. 3 multiple choice options 8/ 32 Which of these statements describes the new methodology C. Net patient service revenue is defined as the total incurred charges, less the for the determination of net patient service revenue: explicit price concession, less any applicable implicit price concession(s) as applied to the specific portfolio of accounts. A. Net patient service revenue is defined as the average 3 multiple choice options payment amount for the payer but not recorded until the end of the month processing is completed. B. Gross patient service revenue is recorded as net patient service revenue until such time as all payments are received. C. Net patient service revenue is defined as the total incurred charges, less the explicit price concession, less any applicable implicit price concession(s) as applied to the specific portfolio of accounts. D. Net patient service revenue is gross revenue minus any contractual adjustments applicable to the account. Any additional adjustments are not recorded until the account reaches a zero balance. E. Net patient service revenue is the sum of the balances of all charges and payments recorded in the accounting period. What is benchmarking? Compare KPIs in an org to an agreed upon average, or expected standard, within the same industry. What are hospital and system MAP Keys and who is it led Stragetic KPIs that set standards for patient-centric revenue cycle excellence in the by? HC industry. Led by HFMA, developed by industry leaders. How many keys are in the MAP Keys? 29 keys (KPIs) 3 multiple choice options What are the 5 major groups in KPIs? 1. Patient Access 2. Pre-Billing 3. Claims 4. Account Resolution 5. Financial Management What is DNFB? Days in Total Discharged Not Final Billed What is DNSP? Days in Total Discharged Not Submitted to Payer What is FBNS? Final Billed Not Submitted to Payer Claims that are held in a claim scubber for additional editing prior to being released to the health plan or govt payer Ex. Claims held in Relay for missing ICN or has been flagged as Duplicate to previous claim What are Net Days in A/R? How fast receivables are collected Other name: A/R days 9/ 32 t Formula for calculating Net Days in A/R. Net Patient Accounts Receivables / Avg Daily Net Patient Service Revenue *Net Pt A/R = the Balance Sheet *Average Daily Net = Income Statement What is A/R Aging Analysis? Aging reports divide the A/R into categories of 0-30, 31-60, 61-90, 91-120 and 120 days based on the date of service/discharge. 3 multiple choice options What are some activities that places an account in DNFB status? - Incomplete charge postings - Incomplete final mec rec coding - Incomplete verification of ins eligibility/benefits 3 multiple choice options What is Cost to Collect? Revenue Cycle Cost divided by Total Pt Service Cash Collected *Revenue Cycle Cost = Pt Access Expense, Pt Accounting Expense and HIM expense What is "suspense" period? Set by a provider to hold a claim to allow the completion of pre-billing activities. 3 multiple choice options What is Cash Collected as Percentage of Net Revenue? Net Collection Rate (NCR) Definition: how much cash you collected as a % of what was available to collect (ratio of Cash to Net Revenue) *type of KPI What is Point of Service (POS) Cash? Represents % of pt Cash collected at or up to SEVEN days after an occasion of service as a % of Total Self Pay cash collected for the period. What is a good POS collections result? Between 25.7% to 45.5% of total Self-Pay collections. 3 multiple choice options What is an acceptable percentage of first submission claim denials? 2% 3 multiple choice options What is the formula to calculate days outstanding for Credit Balances? Dollars in Credit Balance (Days Outstanding) divided by 3-Month Daily Avg of Total Net Pt Service Revenue What is acute care? Short-term medical and nursing care provided in an inpatient hospital setting to trea the acute (brief but severe) phase of a patient's injury or illness. 3 multiple choice options What is non-acute care? Ongoing and long-term health treatment - not any urgent or ED treatment. 3 multiple choice options Accurate identification of the patient is the first step in the scheduling process. Identifiers used in various combination to achieve accurate patient identification include? Full Legal Name, DOB, Sex and SSN 10 / Which of the following statements accurately describes the various Medicare benefits programs: Medicare Part A : IP services, SNF, and HHA Medicare Part B : OP and Professional services Medicare Part C : Managed Care (Advantage) Medicare Part D : RX Medicaid categories are restricted to children, pregnant women and elderly in nursing homes. True or False? False Examples of managed care plans include: - HMO, PPO and EPO plans - POS, Concierge plans, Medicare Advantage plans - Direct contracting for specific services from specific providers - All of the above All of the above Patient Financial Communications best practices include all of the following activities EXCEPT: A. Communicating the details of the patient's insurance coverage including eligibility and benefits B. Collecting payment or initiating the process to immediately remove the patient from the service schedule C. Discussing unpaid balances and providing financial assistance information, as appropriate D. Providing financial counseling including assistance with potential Medicaid eligibility processing B. Collecting payment or initiating the process to immediately remove the patient from the service schedule Which statement includes the required components of an accurate pricing determination? A. T/C and discounts, if any, that may be applicable B. Insurance eligibility, DX and CPT codes, total estimated charges, adjudication calculations based on average payments from the insurance carrier for the service C. Insurance coverage and benefits, service or test involved, DX and CPT codes, total estimate charges, adjudication calculations based on the patient's benefits package D. Chargemaster pricing less the provider's standard discounting amount(s) for hospital services C. Insurance coverage and benefits, service or test involved, DX and CPT codes, total estimate charges, adjudication calculations based on the patient's benefits package 3 multiple choice options What is resource coordination? Resource coordination can include: - Reserving rooms and/or equipment - Ordering devices or supplies - Staffing availability: physicians, nurses, and/or technicians Can a Direct Admit be considered scheduled? Yes, if the physician calls ahead of time to notify that the pt is coming. What is the requirement for patients to be scheduled for Inpatients under managed care plans? Approval/authorization PRIOR to service. What is considered Scheduled Outpatients? - Services receive do NOT involve overnight stay - If overnight, the pt does NOT meet IP acuity criteria (medical necessity) Ex. Ultrasound, CT Scan, PET Scans, MRI, Pulmonary Function Testing, Interventional Radiology, EKGs, EEGs, cathererizations, stress tests, neurology, Ambulatory SX, Pain Management, Lab Tests 11 / What are Scheduled Recurring/Series Patients? - TXs that are ongoing and duration 30 days. - Must be considered as 1 "episode" of care by same ordering physician and DX +Charges related to treatment are entered on 1 acct for multiple DOS +Monthly claim is submitted. Ex. physical therapy, occupational therapy, speech therapy, cardiac rehab svcs, pulmonary rehab, nutrition counseling, behavioral health day programs, IV therapy, chemo, radiation therapy What are unscheduled patients? - Unscheduled IP or urgent patients - Unscheduled OP or walk-in patients - ED - Observations - Newborns What is a Direct Admit? Physician sends the pt directly to the hospital b/c the pt's medical condition meets the required acuity level for admission. Upon admission: URGENT ADMISSION What is the time frame requirement for notification of admission for most health plans? Usually within 24 hours or next Business Day When is Observation used? - Evaluate pts for possible IP admission - Resolve medical problems so pt can be D/C - Treatment expected to last 24hrs - Treat complications following OP SX or procedures When is Observation considered NOT an appropriate status? - Substitute for IP admission or for continuous monitoring - Medically-stable pts who need testing or OP procedures Can an Observation status be used for pts waiting for nursing home placement or as a convenience of the pt, family, physician or hospital? NO Can an Observation status be used as routine preparation for procedures or for routine recovery from diagnostic or surgical services? NO What are skilled nursing units or facilities (SNF)? Non-acute care for pts who do NOT meet criteria for acure care, but still requires IP level of skilled nursing care or rehab services. Ex. orthopedic surgical patients who require intense physical therapy and stroke patients who require comprehensive rehab services What is the requirement for Medicare to cover services in a SNF? The pt was transferred to SNF AFTER at least 3 consecutive days of IP stay for a related illness or injury. EXCEPTION: No hospitalization is required if the pt briefly leaves SNF and is readmitted to the same or another participating SNF within 30 days Is there an exception where Medicare will make payments even if Medicare beneficiaries do NOT meet the three-day IP stay requirement prior to admission to a SNF? YES - requirement may be waived and services may be covered for participating, qualifying ACOs (Accountable Care Organization). How should hospice-related services be billed when a pt is If a hospice pt receives services under the Medicare program is admitted to the admitted to the hospital? hospital for hospice-related services, the hospice program is billed, NOT Medicare. 12 / What are some examples of Home Health Services? - Intermittent Skilled Nursing Care - Physical therapy - Speech-language pathology services - Continued occupational services Is a Physician Order needed for Home Health Services to be covered by Medicare? Yes What are some examples of Durable Medical Equipment (DME)? Wheelchairs, hospital beds, oxygen tanks, CPAP/BiPAP/AutoPAP What is a non-acute clinic? Facility, or part of one, dedicated to the diagnosis and treatment of OPs. Which patients are considered scheduled? A. Observation Patients B. Emergency Department Patients C. Recurring/Series Patients D. Hospice Care C. Recurring/Series Patients What is the unique number assigned to patient upon registration? - Medical Record Number (MRN) - Master Patient Index (MPI) Number - Corporate Patient Index (CPI) Number What are some services that do NOT require a physician's order? - Flu vaccine - Pneumonia vaccine - Screening mammography What are the data elements required on a physician order to be considered VALID? - Patient's Full Legal Name - Date order written - Test or service ordered - DX, coded DX, or narrative description of the reason for the test or service - Name of ordering Physician or allied HP (AHP) - Signature of Physician or advanced practice provider (APP) ordering the test or service What guidelines did Medicare establish to determine which DX, signs or symptoms are payable? - Local Coverage Determinations (LCD) - National Coverage Determinations (NCD) What does a provider need to do if a service is deemed not medically necessary by Medicare? Inform pt PRIOR to service and use the Advance Beneficiary Notice of Noncoverage (ABN) form to document pt was notified. What is the purpose of an ABN? To notify the pt in advance that Medicare may NOT pay for the test/service ordered, the reason the test/service may not be covered, and the cost, which will be billed to the pt. What are the 3 conditions provider must decide in order to properly inform Medicare beneficiaries of potential liability? 1. Statutorily excluded items and services — no required notice 2. Items and services expected to be denied reimbursement — notice must be supplied (e.g., Hospital-Issued Notice of Noncoverage [HINN] or Advance Beneficiary Notice [ABN]) 3. Items or services presumed to be a Medicare benefit — no notice requirements, provider expects to receive payment from Medicare What are Split Claims? Billing method to ensure 3 conditions can be applied to all items and services billed on a single claim to Medicare. 13 / What are Bundled Services under Medicare? - Some Medicare payment policies bundle several items or services into 1 single unit for payment. - ABN has to apply to all items/services bundled, or none at all (bundled unit must be billed as non-covered, or none at all). Is an ABN used for IP services? No, the IP counterpart to an ABN is the Hospital-Issued Notice of Noncoverage (HINN) Provided: - prior to admission, at admission, or at any point during an IP stay if the hospital determines that the care the beneficiary is receiving, or is about to receive, is NOT covered. What are some examples of both financial and clinical paperwork that can be assembled ahead of time by pre- registration? Armbands, labels, charge plates, medical charts, test order sets, signature forms, and payment arrangements. When was HIPAA enacted? 1996 What is a 270 transaction? An outbound inquiry from provider to the health plan. What is a 271 transaction? The response from the health plan to provider's eligibility inquiry. How is Medicare funded? Financed through taxes and general revenue funds. What is Medicaid? Federally aided, state operated program to provide health and LTC coverage for low income people. What is Tricare? Healthcare program of the United States Department of Defense Military Health System. What is Indian Health Service (IHS)? An agency within the Department of Health and Human Services (DHHS) responsible for providing federal health services to Native Americans. Do commercial indemnity plans require authorizations? NO What are self-insured or self-funded plans? Costs of medical care are provided by the employer on a pay-as-you-go basis. What is a liability coverage? Medical coverage (through auto, home or business insurance plans) that cover bodily injury and damages if a patient is at fault for an accident or injury. What are managed care plans? Health insurance plans that contract w/ providers and facilities to provide care for lower costs. 14 / What are Medicare Part A "benefit periods"? Patient remains in the same "benefit period" until he/she is hospitalization free/SNF- free for 60 consecutive days. - A deductible is due each time of re-admission (a new benefit period begins) - Medicare will pay full benefits for up to 60 days - Benefit Period renews after 60 consecutive days of being hospitalization-free/SNF- free What happens when a Medicare beneficiary uses up the 60 days of the "benefit period"? Pt will have 30 co-insurance days. Daily OOP: 25% of current deductible amount What happens after a Medicare beneficiary uses up the 60 days + 30 co-insurance days? Pt can use 60 lifetime reserve (LTR) days. These are once in a life time and never renew. Daily OOP: 50% of current deductible amount What happens if all benefits are exhausted for Medicare Part A? If the pt has Medicare Part B, part B can be billed for svcs covered in the OP environment. How is Medicare Part B funded? General tax revenue and user premiums. Is there a patient responsibility under Medicare Part B Coverage? Yes, there is an out-of-pocket for Medicare Part B. - Annual deductible - Co-insurance payment for all Part B-covered services (NOT including DX Lab Svcs) What is the claim format requirement when billing hospital IP/OP services to Medicare? PAPER : UB-04 (aka CMS-1450) ELECTRONIC : 837-I What is the claim format requirement when billing physician claims to Medicare? PAPER : CMS 1500 ELECTRONIC : 837-P What is required on 837-I and 837-P to Medicare or Medicare Advantage plans? Medicare Beneficiary Identifiers (MBIs) What is timely filing requirement for Medicare? Within 1 Calendar Year from DOS What is a medicaid managed care plan? When a State contracts with another health plan to offer care under specific providers or healthcare facilities. What did the provision of the Patient Protection and States were provided additional funding if benefits were extended to individuals 65 Affordable Care Act (PPACA) in 2014 change? years of age with incomes up to 133% of federal poverty level. 1st time low-income adults without children are guaranteed coverage through Medicaid. Who qualifies for medicaid? - Low-income families, qualified pregnant women and children, + individuals receiving Supplemental Security Income (SSI) - Individuals receiving home and community-based services + children in foster care who are not otherwise eligible - Low-income Americans 65 (after passing of ACA of 2010). 15 / What services are covered under medicaid programs? - IP and OP hospital services - Physician, midwife, and NP services - Nursing home services for 21+ - Pregnancy-related services - Lab and Xray services - Federally qualified health center and rural clinic svcs What is the claim format requirement when billing claims to Medicaid? HOSPITAL - Electronic: 837-I PROFESSIONAL - Electronic: 837-P What is "spend down"? - Out of pocket pt must pay to reduce their income (spend-down) to the Medicaid need standard *Reflected on 837-I using Value Code 66 What are some specific documentation that must be submitted on a claim to Medicaid? - Induced abortions, sterilizations, and hysterectomy - Newborn bills must include birth weight - State-specific requirements must be followed What is the alternative rule to the gender rule for self- funded benefit plans when coordinating benefits? Date of Birth What type of account consequence arises from a patient's failure to pay for a self-pay balance? Bad Debt What is the billing format for Tricare (formerly CHAMPUS)? HOSPITAL: 837-I PROFESSIONAL: 837-P For Tricare, can you combine ER claims with IP claims? No, ER and IP must be separated. What happens if a claim is billed to Tricare without authorization? TRICARE deducts a 10% penalty What is Timely Filing Limit for Tricare? Primary claim - 1 yr from D/C Date Secondary claim - 90 days from Primary payment date What does Tricare Prime cover? Active Duty members and families (at military facilities and POS option) What is Tricare Standard and Extra plan? A fee-for-service plan available to all non-active-duty beneficiaries throughout the US. - includes OP deductibles and co-ins requirements. - type of provider seen determines which option is used. *when non-network provider, the standard option is used. The extra option is used when visiting a network provider. What is Tricare for Life? TRICARE supplement to the Medicare program, only available to Medicare-eligible individuals who are also enrolled in Medicare Part A and Part B benefits. 16 / What is the birthday rule? Coordination of benefits for dependent coverage is based on the birth day and month of each parent; - the plan of the parent whose birth day and month falls first in the calendar year is primary - If both parents have the same birth day and birth month, the parent plan that has been in effect the longest is considered primary. What else does ERISA use to determine COB besides birthdate? ERISA plans may opt to use gender rule. Under the gender rule, the plan provided by the father of the dependent is primary. Which option is a federally-aided, state-operated program to provide health and long-term care coverage? A. Medicare B. Medicaid C. Self-Insured Plans D. Liability B. Medicaid 3 multiple choice options What is a Consumer Directed Health Plans (CDHP)? Health insurance arrangements in which a person have a high-deductible health plan (HDHP) + a personal health account (PHA) that they can use to pay health care expenses not covered by insurance. How does a Medicare Advantage Plan work? Beneficiary pay his/her monthly Part B premium to Medicare + a premium to the Medicare Advantage plan for the extra benefits that it offers, which can include RX cvg. What is an MSA plan? Medical Savings Account (MSA) Plan — a plan that combines a HDHP with a bank account. Medicare pays the plan and the plan deposits money into the beneficiary's HSA (usually deductible). Part D RX coverage is not included; however, MSA enrollees can join a stand-alone Medicare RX plan (PDP and the Part D co-pays will count towards the out-of-pocket spending limit). Can an organization offer discounts to assist uninsured patients with their hospital bills? Yes, an org can apply Self Pay discount and Financial Assistance adjustment, if approved. Must share SP/Good Faith Estimate with patients and explain the discount applied What is the first component of a pricing determination? A. Identify the service or test involved B. Verification of the pt's insurance eligibility and benefits C. Inform the pt that physican services are or are NOT included D. Use a documented workflow or other tool for guidance in determining an estimate B. Verification of the pt's insurance eligibility and benefits What are the two types of self-pay dollars? SELF PAY (UNINSURED) SELF-PAY BALANCE AFTER INSURANCE Does a non-contracted provider need to abide by contractual allowance? No, since there is no discounting provision for non-contracted health plans. 17 / What is a prompt-pay discount? A discount given to self-pay pts to entice them to resolve their debt immediately. What is the time limit on prompt-pay discount? Typically 10 days for settlement of obligation. What is a short-term payment? Payment plans, typically a monthly payment that is agreed upon between the pt and the provider. Must be met within time frame. No interest charged. Can patients apply for loans to pay for their medical bills? Yes, some hospitals offer programs which allow a pt to obtain credit through a bank loan that is paid directly to the hospital by the lending institution. What is the guideline for qualification when a pt is referred to Financial Assistance Program (FAP)? The basis of qualification is typically the Federal Poverity Guidelines (published annually by the federal govt). What are the 4 categories of information that providers request from patients to assess for Financial Assistance? Demographic, Income, Assets and Expenses What are some examples of liquid assets are used to determine financial assistance qualification? Savings accounts, investments, additional vehicles, campers, boats, etc. What is considered "medically indigent"? If the oustanding medical bills EXCEED a defined dollar amount / defined % of assets as specified in the provider's FA policy. EMTALA prohibits inquiries about health plan or liability payer information if the inquiry will delay examination or treatment. What other requirements apply to the Emergency Department registration work? ALL OF THE ABOVE The primary types of coding systems curerntly used in healthcare: A. HIM; HCAPCS B. ICD-9/CPT/HCPCS Codes C. ICD-10-CM/ICD-10-PCS; CPT/HCPCS codes D. FASB; ASC 606 C. ICD-10-CM/ICD-10-PCS; CPT/HCPCS codes These are four code sets that provide health plans with additional information as they process claims. 1. Condition codes 2. Occurence codes 3. Occurence span codes 4. Value codes For SNF, care is covered if which of the following factores are present: A. The pt requires SN or rehab on a weekly or semi-weekly basis B. The pt requires skilled svcs on a daily basis and those svcs can only be provided on an IP basis in a SNF C. The pt has not been an IP in a hospital for at least 3 Calendar days prior to admission to the SNF D. ICF beds are not available at TOA to the SNF B. The patient requires skilled svcs on a daily basis and those svcs can only be provided on an IP basis in a SNF 18 / DRG's are a system of classifying inpatients on the basis A relative weight X (multiplies) established base payment rate = reimbursement for of diagnoses, procedures, and co-morbidities for purposes a specific DRG. of payment to hospitals. Each DRG includes: For exceptionally costly cases over a set dollar amount, an outlier payment is added to the calculated payment. PPO networks represent one form of discounting commonly used by commercial payers. The silent PPO represents: Health plans apply GENERIC PPO RATES to discount a provider's claims, even though there is no contractual arrangement between the silent PPO and the provider Which of the following statements are NOT true about timely filing limitations? Payers will waive timely filing denials for claims filed over a year from DOS (unless there are proper documentations showing a requirement for approving claims PTFL, i.e HMS audits) Is the hospital allowed to call for prior authorizations for ED services? Prior auth is NOT allowed for ED services if medical screening and stabilizing TX has NOT been provided. What is patient dumping? Referring a pt to another facility for care that should be completed while the pt is in the ED. When is it okay to transfer a patient prior to stabilization? The only exception is when the facility clearly does NOT have the appropriate resources to treat the pt. What is the UB-04 coding rules for newborn babies? Newborns delivered OUTSIDE of the hospital and subsequently transported to the hospitals are separately identified. What are the rules used for COB of newborns if both parents have insurances? Gender Rule (Father is primary, typically) Birthday Rule (Whoever is older in YEAR, is Primary) What is required on an IP claim/bill to denote the date span of contiguous OP hospital services that preceded the IP admission? OCCURENCE SPAN CODE 72 3 multiple choice options What are the types of hospital Registration Forms? - ED Sign In Sheet - Consent to Treatment - Conditions of Admission - Privacy Notice - Important Message from Medicare - Medicare Outpatient Observation Notice (MOON) - Advance Directive and Medical Power of Attorney - Patient's Bill of Rights What is another name for Bed Control? Census Management 3 multiple choice options How are daily room charges calculated for inpatient? Based on the pt's location and the LOC at midnight each day What are the 3 types of case management reviews? - Prospective review (pre-cert) - Concurrent review & D/C planning (during service) - Retrospective review (after service) 19 / What is the purpose of case management? Monitor the progression of high resource consumptive cases to help ensure effective utilization of resources during the care of the pt and maximize pt outcomes 3 multiple choice options In what manner do case managers assist revenue cycle staff? Providing assistance with written appeals to health plans related to utilization 3 multiple choice options When do R&B (Room and Bed/Board) charges get From the midnight census, based on the room and accommodation/LOC associated posted? w/ the room that the patient occupies at midnight 3 multiple choice options When do ancillary charges get posted and charged? POSTED - when the service or supply is ordered or when a result is reported. CHARGE - based on length of time (surgery) or acuity (nursing) How are ancillary charges generated? Scanning barcoded items or other forms of docs as items are used. How does the hospital audit ancillary charges? Charge audit report that is verified against logs, schedules, and med rec to make sure all resources used during pt care are charged to the correct acct. What are the benefits of timely and accurate capture of charges? - Increases net collections and cash flow (billing) - Decreases research efforts for issues related to duplicate charges and charge codes - Ensures that bills are not held for Late Charges What is a chargemaster? List of: (may be billed to IP or OP) - Services/procedures - Room accomodations - Supplies - Drugs/biologics - Radiopharmaceuticals What are the Core Elements of a Chargemaster? - CDM # (assigned to a given line item) - Department # (revenue generating area) - Billing/Charge Description (appears on claim) - Charge Amount (assigned to chargemaster line item) - CPT/HCPCS - Modifiers - Revenue codes - General Ledger (GL) Number What is a CPT Code? Describes treatments & procedures performed (5-digit format) + Services, procedures and drugs - Maintained by the American Medical Association(AMA) When are CPT codes updated? January and July of each year What a HCPCS code? Describes services, procedures, durable medical equipment (DME), supplies, drugs, biologics, and radiopharmaceuticals. - Maintained by Centers for Medicare and Medicaid ( CMS) When are HCPCS codes updated? Continually throughout the year 20 / What are Revenue Codes? 4-digit # code that categorizes/classifies a line item in the chargemaster - Established by the National Uniform Billing (NUBC) What are HCPCS Level I codes? - 5 digit numeric - Approved by AMA's CPT 4 codes - CPT-4 codes are included within the HCPCS code What are HCPCS Level II codes? - Begin with a letter (A-V) followed by 4 numeric digits - Approved by CMS - Classifies supplies and non-physician svcs (i.e DME, ambulance svcs, med/surg supplies, and drugs) What are HCPCS Level III codes? - Begin with letter (W-Z) followed by 4 numeric digits - Approved by Medicare Administrative Contractors (MACs) - Not common and used to describe new procedures not yet developed in Level 1 and II List of HCPCS Level I Modifiers 22 - Increased procedural services 23 - Unusual anesthesia 24 - Unrelated E&M service by same physician during post-operative period 25 - Significantly separate E&M service by same physician on same day of the procedure or service 26 - Professional component 50 - Bilateral procedure 51 - Multiple procedures 52 - Reduced services 73 - Discontinued outpatient procedure prior to anesthesia administration 74 - Discontinued outpatient procedure after anesthesia administration List of HCPCS Level II Modifiers LT - left side RT - right side E1 - Upper left, eyelid E2 - Lower left, eyelid E3 - Upper right, eyelid E4 - Lower right, eyelid FA - Left hand, thumb F1 - Left hand, second digit F2 - Left hand, third digit F3 - Left hand, fourth digit F4 - Left hand, fifth digit F5 - Right hand, thumb F6 - Right hand, second digit F7 - Right hand, third digit F8 - Right hand, fourth digit F9 - Right hand, fifth digit LC - Left circumflex, coronary artery RC - Right coronary artery List of HCPCS Level III Modifiers These modifiers differ significantly because they are assigned by each MAC. WA - Cosmetic surgery XI - Administration of a Food and Drug Administration (FDA)-approved drug How many modifiers can be used per line in the current filing formats? Up to 4 modifiers. If more than 2 modifiers need to be reported next to a CPT code, repeat the CPT code with the additional modifier appended. When does CMS update the official list for CPT procedure codes? Annually, usually in October with an Effective Date of January 1 the follow year. 21 / Why is it critical that a chargemaster is reviewed and updated regularly? A. To ensure it supports and represents the services provided within the organization. B. To ensure the most appropriate measure of the utilization of resources. C. So the CPT databases can have the most current and accurate information. D. Because charge descriptions can vary greatly between providers. A. To ensure it supports and represents the services provided within the organization. What is "hard-coding"? When code is assigned via the chargemaster. What is "soft-coding"? When a HIM coder reviews and/or assign DXs or CPT codes (special handling) Which organization developed ICD-10 Codes? ** International ICD-10 codes - WHO (World Health Organizations) ** ICD-10-CM codes - Centers for Disease Control's National Center for Health Statistics (NCHS) ** ICD-10-PCS codes - CMS What is ICD-10-CM? Diagnostic-classification system consisting of 68,000 DX codes - Principle - Secondary - Presenting - Complications - Co-mobidifites What is ICD-10-PCS? Procedure coding system consisting of approximately 87,000 CPT Codes What are new reimbursement models? - Value-based purchasing - Bundled payments - Medical home models What are the 2 types of standard claim forms? HOSPITAL - UB-04 - 81 form locators - Used by hospitals, hospice, rural health clinics, SNF) PROFESSIONAL - CMS-1500 - 33 major items, subdivided into 55 details items - Used by physicians, allied health professionals, CRN, and CRNAS, HHAs, DMEs, etc) Source of data for form locators on UB-04. 40% PATIENT ACCESS : 32 form locators related to demographics and insurance data 11 % SERVICE or ANCILLERY DEPT : 9 form locators related to charging or TOS documentation 20% HIM : 16 form locators related to the coding of services or documenting charge information 20% BILLING OFFICE or SYSTEM GENERATED : 16 form locators completed as applicable during the post-encounter process 9% RESERVED or NOT USED : 8 form locators 2 multiple choice options 22 / Source of data for form locators on CMS-1500. 47% PATIENT ACCESS : 26 form locators 13 % SERVICE DEPT or PROVIDER RESP : 7 form locators 7% HIM : 4 form locators 27% BILLING OFFICE or SYSTEM GENERATED : 15 form locators 6% RESERVE for Future Use : 3 form locators 2 multiple choice options What are condition codes? Describe conditions or events that apply to the period being billed on the claim. Ex.) Condition Code 02 = Employment Related What are occurence codes? Provide additional information pertaining to the period being billed on the claim. Ex.) Occurence Code 04 (with specific date of accident) = Employment related accident What is an occurence span code? Used for an event that spans a period of time Ex.) IP stay not covered d/t LOC, occurrence span code 74 would be entered with specific FROM and TO dates What are value codes? Represent data of monetary nature that are necessary for the processing of claim Ex.) Value Code 01: most common semi-private room rate in a hospital **FORMAT ON CLAIM: VALUE CODE 01 - $550.00 What are claim edits? Rules developed to verify the accuracy and completeness of claims based on each health plan's policies What is the official name for the HIPAA electronic transaction standards and what are the applicable entities? VERSION 5010 What is the National Council for Prescription Drug Program (NCPDP) standards developed for pharmacy and supplier transactions? Version D.O. 3 multiple choice options What is the National Council for Prescription Drug Program (NCPDP) standards developed for Medicaid pharmacy subrogation? Version 3.0 3 multiple choice options Who is the authoring entity for HIPAA claims-related electronic transactions and their operating rules? Council for Affordable Quality Healthcare (CAQH) 3 multiple choice options What is Electronic Data Interchange (EDI)? Technology used for translating, standardizing, and sending transactions electronically What is the term used for additional information that is on electronic data sets but NOT on UB-04 paper form? LOOPS 3 multiple choice options 23 / What is an interim bill? Interim billing in the acute care setting is typically used for extended IP stays. When a pt remains an IP for 30 days, the facility is permitted to submit a bill every 30 days. What is the claim format for Rural Health Clinic (RHC) services? FORMAT: UB-04/837-1 Specific CPT codes are collapsed into a single revenue code (520 or 521) OTHER FORMAT: CMS 1500/837-P is frequently required to bill Medicaid and other health plans and liability payers What are non-RHC services and how are they billed? NON-RHC Services : IP services, svcs given to MCARE beneficiaries in a Part A SNF, acillary = lab, EKGs, pulmonary fx testing, and TC of x-ray svcs BILL TO : Medicare Part B under fee schedule What are the requirements for a pt to elect hospice care? - Medicare Part A beneficiary - certified as terminally ill What are covered hospice services? - Nursing Care - Physical, Occupational, and Speech Therapy - Medical social services - Physican services - Counseling services - Medical appliances and supplies - HHA and homemaker services - Short-term IP care: * Respite care for relieft of pt's caregiver * General IP care (pain control/symptom mgmt); ex. med adjustments, or pt's fam unwilling to permit the needed care to be performed in the home * Exception to the above: short-term IP care cannot be provided in a VA or military hospital b/c MCARE cannot pay for svcs which another govt agency has paid or is obligated to pay What are the 2 statutory exclusions from hospice coverage? 1. Services are deemed not reasonable or medical necessary 2. Items / services constitute custodial care (not a covered LOC) What other hospice service situations cannot involve the limitation of liability provision and require review + proper coordination of benefits assignment? - payable under state of federal W/C - denied b/c pt has NOT been certified as terminally ill - denied b/c pt has already received 210 days of hospice benefits Are hospice services covered for Medicare benefiaries who are in SNF? COVERED: Professional management of pt's hospice care NOT COVERED: room and board What is the structure for hospice reimbursement rate? 1 out of 4 pre-determined rates for each day of hospice. Rate paid for any given day varies depending on LOC. The 4 rates are prospective rates, no retroactive adjustments other than statutory "cap" on overal payments and limitations on payments for IP care. How is Routine Home Care rate calculated (hospice)? Flat RHC rate per day (regardless of volume or intensity of service) ALSO paid when pt receives hospital care for a condition UNRELATED to the terminal condition How is Continuous Home Care rate calculated (hospice)? CHC rate / 24hrs = hourly rate 24 / How is Inpatient Respite Care rate calculated (hospice)? - Max: 5 days at a time (include DOA but exclude DOD) - 6+ days are paid at the RHC rate How is General Inpatient Care rate calculated (hospice)? Level A, C, and D : one rate/per day Level B : based on # of hours of continuous care provided that day When is the hospice cap period? October 1 - September 30 (standard fed fiscal year) 3 multiple choice options How is the payment for Hospice Physician Services *CONTRACTED: MAC pays the physician the lesser of the actual charge OR 100% determined? of the Medicare reasonable charge + the daily rate (counted towards hospice cap) *NON-CONTRACTED: 80% of Medicare reasonable charge (NOT counted towards hospice cap) What is the Discharge Status code for when a pt is D/C from acute service to SNF? 03 - Discharge/Transferred to SNF For hospitals with approved swing bed arrangement (approved by Dept of Health and Human Services), use code 62 - Swing Bed What is the standard benefit period for SNF? 100 days per benefit period Include: 20 full coverage days + 80 additional days subject to co-insurance calculated at 1/8th of the IP deductible No limit on # of benefit periods a pt may have, as long as they are entitled to hospital insurance (part A) Are Clinical Diagnostic Laboratory Tests covered under SNF? No What is the claim format for SNF inpatient services? UB-04/837-I with TOB 22x How are payments to suppliers for ambulance services calculated? Under 1 of the follow 4 methods: 1. All inclusive base rate relfecting all services, supplies, and mileage 2. Base rate to include supplies with a separate charge for mileage 3. Base rate to include mileage and services but separate charges for supplies 4. Base rate with separate charges for supplies and mileage How are HBP (Hospital-Based Physician) claims billed? FORMAT: CMS 1500/837-P If physicians are paid salary/percentage methods, hospital bill patients. Fee-For-Service (FFS) HBPs bill their patients directly What is the patient financial responsibility if he/she is seen at a provider-based clinic? D/T the status of the clinic, their would be 2 claims: a physician + a clinic claim. Pt may have: 2 copays, 1 copay + 1 coins pmt, or another combination What are some Medicare eligible telehealth services? ONLY under Traditional PART B: * Office or other OP visits (CPT ) * Individual & group kidney disease education services (HCPCS G0420 and G00421) * Telehealth consultations, ED or initial IP (HCPCS G0425 - G0427) 25 / 1 What is the claim format for professional telehealth services? FORMAT: CMS 1500/837-P DISTANT SITE PRACTIONER CLAIM * Modifier GT - via interactive audio and telecommunication systems * Modifier 95 (for 2020) - synchronous telemedicine services rendered via a real- time interactive audio and video telecommunications system. ORIGINAL SITE CLAIM * HCPCS Q3014 - original site facility fee (location of the pt at the TOS) * Service Code 02 for all telemedicine services Which statement is NOT a unique billing rule specific to providers? A. Overall aggregate payments made to a hospice are subject to a "cap amount", calculated by the MAC at the end of the hospice cap period. B. With the exception of physician services, Medicare reimbursement for hospice care is made at one of four pre- determined rates for each day of hospice care. C. When billing services on a UB-04/837-I, specific CPT codes are collapsed into a single revenue code (520 or 521). D. A patient may be balance billed for whatever amount the non-contracting physician charges above the health plan's reimbursement amount. D. A patient may be balance billed for whatever amount the non-contracting physician charges above the health plan's reimbursement amount. 3 multiple choice options What is the billing format for COVID-19 Testing? - OP laboratory - Reference laboratory services with Modifier CS + appropriate DX and HCPCS What is the Cost Sharing for Covid-19 Testing? SCENARIO 1: tested in ED, dr's office, Urgent Care or other ambulatory location, NOT admitted to acute = cost sharing is waived, bill claim with CS modifier SCENARIO 2: treated in ED, then admitted to IP = cost of ED + test are rolled into IP visit SCENARIO 3: tested in ED, then admitted to OBS = bill claim as OBS with CS modifier Which of the following statements does not apply to billing B. Telemedicine claims are not payable if the patient conducts the telemedicine visit during the COVID-19 public health emergency: from home. A. Hospitals may change a sub-acute unit into an acute 3 multiple choice options care unit without advanced approval from CMS. B. Telemedicine claims are not payable if the patient conducts the telemedicine visit from home. C. CMS developed the concept of hospitals without walls to increase ICU and med-surge inpatient capacity during the COVID-19 pandemic. D. Cost sharing has been waived for testing for COVID-19 in the ED, physician office, urgent care center or other ambulatory location. What is a contractual allowance? The difference between the provider's charges and the health plan's payment (excluding patient liabilities) 26 / Types of contracted payment models. - Percentage Discount - Per Diem Payment (Fixed Rate per day) - Diagnostic Related Group (DRG) - Ambulatory Payment Classification - Fee Schedule - Case Rates - Package (Episodic) Pricing - Bundled Payments - Capitation - Fixed Contracting - Stop-Loss - Stop-Loss Provision What is a disavantage of Percentage Discount? No incentive to control costs for the plan. What is a disavantage of Per Diem Payment? No incentive to reduce the length of stay and the number of IP days (only incentives to reduce the cost per day). Which version of the DRG concept does Medicare use? Medicare Severity-DRGs (MS-DRGs) What is Ambulatory Payment Classification (APC) and how - Divides OP services into ~600 CPT groups are the rates calculated? - Each APC are assigned a relative payment weight based on avg cost of svc within the APC - Adjusted by geographic area based on wage levels - Some services are packaged into 1 payment What are "comprehensive APCs" or C-APCs? New category of codes created by CMS where CMS provides 1 single payment. Status Indicator: J1 What services are NOT covered under APCs? - Ambulance - DME - Physical Therapy - Occupation Therapy - Lab - Screening - Mammography - Dialysis services for pts with ESRD How are claims paid under Fee Schedule? Reimbursement is based on a negotiated set fee for the specific HCPCS / CPT code regardless of the provider's charge. How are claims paid under Case Rates? Paid on an agreed upon rate (fixed price) for a specific service Common in: Cardiology, Orthopedics, Oncology, Transplant Services, and OP procedures What is Package (Episodic) Pricing? A lump sum or bundled payment is negotiated between the health plan and some or all providers for some or all of the services typically associated with a given procedure, including hospital, surgical, anesthesia, radiology, and other provider services. Ex.) cosmetic procedures, sterilization, in-vitro fertilization, and maternity services How are claims paid under Capitation? PER MEMBER PER MONTH Provider receives a flat fee every month for taking care of a pt enrolled in a managed healthcare plan, regardless of the cost of that individual's care 27 / What is a Stop-Loss Provision? Provision found in health plan contracts that provides protection for medical expenses that exceed certain levels Credit balances may be created by any of the following activities EXCEPT: A. Incorrectly posting allowances or incorrect payment estimates B. Late credits processed after a claim is billed C. Duplicate payments D. Credits to pharmacy charges posted before the claim final bills D. Credits to pharmacy charges posted before the claim final bills 3 multiple choice options Which of the following statements represent common reasons for inpatient claim denials: A. Failure to obtain a required pre-authorizations; failure to complete a continued stay authorization and services provided which were not medical necessary. B. Providing an inappropriate level of care as supported by the documentation provided with the claim C. An omitted HCPCS code D. The APC payment was incorrectly calculated by the provider A. Failure to obtain a required pre-authorizations; failure to complete a continued stay authorization and services provided which were not medical necessary. 3 multiple choice options A 68 year old patient, a Medicare beneficiary, was in a car B. The provider must first bill the auto insurer; however, after a period for 120 day