CRCR Cohort 6| 72 Questions with Answers 2023,100% CORRECT

CRCR Cohort 6| 72 Questions with Answers 2023 EMTALA - CORRECT ANSWERS- Emergency Medical Treatment and Labor Act - requires hospitals to provide a medical screening examination and any needed stabilizing treatment to every person presenting at an ED and requesting medical evaluation or treatment - EMTALA prohibits inquiries about insurance or payment if the inquiry will delay examination or treatment MRN - CORRECT ANSWERSMedical Record Number. Will have 1 MRN wherever they go in the facility (Cerner) EDI - CORRECT ANSWERSElectronic Data Interchange is the technology used for translating, standardizing, and sending transactions electronically The outbound inquiry from the provider to the payer Transaction includes the identification number and the date of birth of the insured party UB-04 - CORRECT ANSWERSHospital claims submitted via UB-04 Electronic version is the 837i CMS 1500 - CORRECT ANSWERSStandard professional services claim form. Electronic version is the 837p Clean Claim - CORRECT ANSWERSa clean claim is defined as a claim that is sent to a payer either electronically or on paper that has no defect, impropriety, or particular circumstance requiring special treatment that prevents prompt payment HCPCS (hic pics) - CORRECT ANSWERSHealthcare Common Procedure Coding System Created to provide standardized coding system for describing specific items and services provided in the delivery of healthcare Procedure used to fix diagnoses. Outpatient procedures Created to make up for what was lacking in the CPT codes - drugs, supplies, etc. Claim Edits - CORRECT ANSWERSClaim Edits are rules developed to verify the accuracy and completeness of claims based on each payer's policies Claim editing lets providers identify and resolve claim issues to ensure clean claim submission to the payer Result is prompt payment, reduced AR outstanding, and increased cash flow Managed Care Plans - CORRECT ANSWERSComprehensive healthcare plans that attempt to reduce costs through contractural agreements with providers and through care management initiatives Common billing rules for managed care plans include coordination of all care by the primary care physician and obtaining the appropriate authorization and referrals Authorization and referral numbers must be included when submitting claims. Ex - PPO, HMO, EPO, POS Medicare Part A - CORRECT ANSWERSbenefits provide coverage for inpatient hospital services, skilled nursing care and home healthcare. Hospital Care Medicare Part B - CORRECT ANSWERSBenefits are available for outpatient and professional service coverage, but the beneficiary must pay a monthly premium for the additional coverage. Pays for physician visits, non-hospital services, X-rays, lab tests, PT, emergency room visits, etc. HICN - CORRECT ANSWERSHealth Insurance Claim Number APCs - CORRECT ANSWERSAmbulatory Payment Classifications Government's method of paying for facility outpatient services for Medicare. APC payments are made to hospitals when the medicare outpatient is discharged from the ED or clinic, or is transferred to another hospital that is not affiliated with the initial hospital where the patient received outpatient services. ABN - CORRECT ANSWERSAdvanced Beneficiary Notice. Mechanism used by providers to explain to Medicare beneficiaries that the ordered test or services probably will not be covered by the Medicare program because the diagnosis info provided by the physician does not support the need for these services. By providing the notice in advance the Medicare beneficiary is given the cost of the test and the option to refuse or pay for the service. Allows the beneficiary to make informed decisions about whether or not to receive the items or services which he/she may pay out of pocket. Medicare Part C - CORRECT ANSWERSMedicare Advantage. managed care that must cover services in Part A and B and usually covers prescription drugs. Additional premiums and cost-sharing obligations will vary by plan. Provdides private managed care or preferred provider plans to Medicare beneficiaries Medicare Part D - CORRECT ANSWERSPays for prescription drugs. Extra premium Critical Access Hospitals - CORRECT ANSWERSPurpose is to keep small rural hospitals open by providing higher payments. hospitals with 25 or fewer beds located at least 35 miles from another facility that offers 24 hour hospital services CPT Code - CORRECT ANSWERSCurrent Procedural Terminology Codes. Codes created by AMA to create a uniform system for cataloging medical, surgical, and diagnostic services. Provides a single code for each physician visit and the other procedures. There are 6 sections of codes: (1) evaluation and management (E&M) codes covering office visits, emergency room visit, preventative (2) anesthesia codes (3) surgical codes (4)radiology codes (5) pathology (6) medicine codes RVU - CORRECT ANSWERSRelative Value Unit Common metric to compare the human and other resources needed to provide physician services. RVU system gives each CPT code a "value" that is supposed to reflect the amount of resources needed to deliver the service Made up of physician's work, practice expenses, and malpractice insurance. Each of the 3 RVU components is multiplied by a factor known as the Geographic Practice Cost Fee for service - CORRECT ANSWERSCharge by the unit of service ex - charge or x-ray, cast, etc. Main problem - providers induce demand = non-essential care Package pricing or "bundled charges" - CORRECT ANSWERSnumber of related services in one price; reduces provider-induced demand becayse fees are inclusive of all inclusive of all bundled services. There is evidence that prosepectively set bundled fees reduced health care spending without compromising quality of care, bundled payments for Care Improvement (BCPI) initiative HMO - CORRECT ANSWERSHealth Management Organization HMO salaries its own providers Capitation (set amount of money) APC (reimbursement methodology) - CORRECT ANSWERSAmbulatory Payment Classification System Very similar to DRG, takes all of CPT and groups them together, and reimburse that APC. Similar to DRG, but outpatient APG (reimbursement methodology) - CORRECT ANSWERSAmbulatory Patient Group Medicaid version of grouping and reimbursement Revenue Codes - CORRECT ANSWERSDescriptions hospital service provided, tells an insurance company whether the procedure was performed in the emergency room, operating room, or another department Ex: 250 = pharmacy, 300 = lab, 360 = operating room DRG (reimbursement methodology) - CORRECT ANSWERSDiagnosis Related Group ICD-10 - CORRECT ANSWERSInternational Classification of Diseases version 10 Diagnoses Ex - primary hypertension = 100 E&M Codes - CORRECT ANSWERSEvaluation and Management Codes Doctors use various codes (1 to 5 to describe the amount of work covered in an appointment) HIM - CORRECT ANSWERSHealth Information Management Distribute/release of medical records, analyze information, coding - look at DRG and use that DRG or develop their own coding for patient stays to ensure reimbursement CMS - CORRECT ANSWERSCenters for Medicare and Medicaid US Federal agency that administers Medicare rules and payment. Also establishes the guidelines by which individual states administer Medicaid and children's Health Insurance Program (CHIP) HIPAA - CORRECT ANSWERSHealth Insurance Portability and Accountability Act created a set of uniform standards a nd had several main objectives; here are just a few: - to improve portability and continuity of health coverage when emoployees change jobs - ti combat waste, fraud and abuse in health insurance - to simplify the administration of health insurance - to protect the privacy and security of health information ARRA - CORRECT ANSWERSAmerican Reinvestment and Recovery Act Established, among other things, interim breach notification requirements and additional responsibilities for business associates to comply with the Security Rule and portions of the Privacy Rule or face penalties MSPQ - CORRECT ANSWERSMedicare Secondary Payer Questionnaire PPO - CORRECT ANSWERSPreferred provider organization Providers paid on FFS fee schdule MACRA - CORRECT ANSWERSMedical and CHIP Reauthorization Act PCS - CORRECT ANSWERSProceduraal Coding System Exact same as CPT for inpatient Ambulatory Surgery Center - CORRECT ANSWERSAmbulatory 24 hours Freestanding (not affiliated with hospital) - flat reimbursement per procedure - billing form 1500 Affiliated with a hospital - reimbursement like hospital - billing for 1500 and UB-04 ACO - CORRECT ANSWERSAccountable Care Organization Formal alliance of people coming together for a common purpose. Created under the ACA, its purpose is to foster change in patient care so as to accelerate progress towards a three part aim: better care for individuals, better health for populations, and slower growth costs through improvements in care. HFMA - CORRECT ANSWERSHealthcare Financial Management Association Leading membership organization for health care financial management executives and leaders. Respected thought leader on top trends and issues facing the health care industry. DNFB - CORRECT ANSWERSDischarge Not Final Bill Finished service, but have not sent claim out Charity - CORRECT ANSWERSInability to pay and does not qualify for Medicaid assistance. Often based on a sliding scale discount amount up to a 100% discount based on the patient's financial status. Each provider determines the amount of the discounted or free care Bad Debt - CORRECT ANSWERSUnwillingness to pay the entire account or the balance of an account not paid by insurances ESRD - CORRECT ANSWERSEnd-Stage Renal Disease - A/R Days - CORRECT ANSWERSDays of Revenue in Receivables Measures how fast receivables are collected (Net Patients AR over period of months)/[(Net patient services Revenue)/(365)] MAR - CORRECT ANSWERSMeds Administration Record Used to track when IV, etc. starts and stop for reimbursement with CMS DME - CORRECT ANSWERSDurable Medical Equipment Medical equipment that is prescribed by a doctor for use in the home. Ex - walkers, wheelchair, hospital bed, respiratory supplies, CPAP Accounts Receivable (AR) - CORRECT ANSWERSrepresents money owed by third-party payers and patients to the provider for health care services ATB - CORRECT ANSWERSAged Trial Balance standard report that shows accounts receivable totals by financial class and aging (typically 30 day) from the moment the claim was submitted to the payer. Good indicator of how fast the organization is liquidating its assets Bad Debt Agency - CORRECT ANSWERSthird-party that focues on working self-pay claims including patient balances remaining after insurance has paid. Case Management (CM) - CORRECT ANSWERSmethod of managing the provision of health care with the goal of improving continuity and quality of care while lowering cost. Areas include: Bed management, case management, social work, discharge and utilization review CMI - CORRECT ANSWERSCase Mix Index The average DRG weight for all a hospital's Medicare volume. Financial department monitors case-mix index, and in an ideal world, hospital's CMI would be high as possible. a high CMI means the hospital performs big-ticket services and therefor receives more money per patient CDM - CORRECT ANSWERSCharge Description Master charge master is a file that contains a list of chargeable services and the respective charge for the procedures. Timeley and accurate CDM maintenance is crucial Charity Care - CORRECT ANSWERSinternal, hospital-specific policies by which a patient's health care charges are determined to be uncollectable after an investigation Clearinghouse - CORRECT ANSWERSCovered entity that processes or facilitates the processing of information received from another covered entity in a nonstandard format or containing nonstandard data content into standard data eleents or a standard transaction Facilitates calims submissions, remittance processes and eligibility verification transactions among others Compliance - CORRECT ANSWERSCompliance issues heavily deal with Medicare and Medicaid and its responsibility of healthcare facility to follow through with burden of proof of knowing the statues and regulations that govern the federal programs Medical Necessity - CORRECT ANSWERSOutpatient MEdical necessity refers to the process of checking a patient's appointment or procedure information against the diagnosis to determine if services to be provided are medically necessary based on criteria laid out by the insurance carrier. OIG - CORRECT ANSWERSOffice of Inspector General Self polices the hospitals FERA - CORRECT ANSWERSFraud Enforcement and Recovery Act Amends False Claims Act to close loopholes and enhance government to successfully pursue entitites who improperly receive funds Roles of Chief Compliance Officer - CORRECT ANSWERSOversees high-level personnel. Reports directly to board of directors. Responsible for operational aspects NPI - CORRECT ANSWERSNational Provider Identifier unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses will use the NPIs in the admin and financial transactions adopted under HIPPA Stop-Loss Coverage - CORRECT ANSWERSInsurance bought by a business that self-funds its worker's healthcare to limit how much it might pay Utilization Review - CORRECT ANSWERSReview conducted by professional healthcare personnel of the appropriateness of, quality of, and need for healthcare services provided to patients Internally-based hospital program and an insurer-based program which seeks to confirm that appropriate levels of care are provided based on the patient's condition. Capitation - CORRECT ANSWERSPayment method where the provider receives a flat fee every month for taking care of an individual enrolled in a managed healthcare plan. Also known as per member, per month payment and ensures paymen for as long as an individual is enrolled in the plan Two Midnight Rule - CORRECT ANSWERSAllows hospitals to account for total hospital time (including outpatient time directly preceding the inpatient admission) when determining if an inpatient admission order should be written based on the expectation that the beneficiary will stay in the hospital for two or more midnights receiving medically necessary care. In order for patient to be admitted as inpatient status, patient needs projecting stay in hospital for at least 2 midnights Acute - CORRECT ANSWERSHospital CDI - CORRECT ANSWERSClinical Documentation Integrity In charge of looking through physician documentation and making sure we are assigning the correct diagnoses to the patients. Looks for correctness and as much information as possible Looking at physician's ICD-10 Codes and DRGs specifically Embedded Partners - CORRECT ANSWERS3rd party that is seemingly unseen in Cerner's solutions Ex - Address verification, etc. are partners embedded into Cerner solutions UR - CORRECT ANSWERSUtilization Review An assessment of the appropriateness and economy of an admission to a healthcare facility or a continued hospitilization Patient Bill of Rights - CORRECT ANSWERSDeveloped to promote and ensure healthcare quality and value and protect consumers and workers in the HC system. 1. The right to information to assist patients in making informed decisions about their health plans, facilities and professionals 2. Right to a choice of healthcare proividers that is sufficient to ensure access to appropriate high quality healthcare 3. Right to access emergency health services when and where the need arises 4. RIght to fully participate in all decisions related to their healthcare 5. Right to considerate, respectful care from all members of the healthcare industry at all ties and under all circumstances 6. RIght to communicate with healthcare providers in confidence and to have confidentiality of their info etc. Discharge Process - CORRECT ANSWERSPhysician must write discharge order Case management discharge planning must be finalized Appropriate discharge instructions must be provided to the patient When patient leaves, registration system must be updated to reflect the correct date and time of discharge, and the correct disposition code EMPI - CORRECT ANSWERSEnterprise Master Patient Index Searching for patient? Medicare 60 days window - CORRECT ANSWERS***