Page 1 of 74
HFMA CRCR {CERTIFIED REVENUE CYCLE
REPRESENTATIVE} COMPREHENSIVE ACTUAL
EXAM PREP 2026 ALL QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES ALREADY A GRADED WITH
EXPERT FEEDBACK | NEW AND REVISED
1. A hospital’s revenue cycle director notices a steady increase in days in accounts
receivable (A/R) over the past three months. Which of the following key
performance indicators (KPIs) would provide the most immediate insight into
whether the issue is related to claims processing delays?
A. Net collection rate
B. Claims denial rate
C. Bad debt percentage
D. Point-of-service collection rate
Rationale: A rising claims denial rate directly contributes to increased days in A/R
because denied claims require rework and resubmission before payment can be
received. The denial rate is a leading indicator of claims processing efficiency. Net
collection rate (A) measures overall effectiveness of collection efforts after all
adjustments, but it does not isolate the impact of denials. Bad debt percentage (C)
reflects accounts written off after exhaustive collection efforts, which is a lagging
indicator. Point-of-service collection rate (D) focuses on front-end collections and
does not address back-end claims processing delays.
2. During pre-registration for a scheduled outpatient surgery, the patient access
representative verifies insurance eligibility and learns the patient has
a 2,500annualdeductiblethathasnotbeenmet.Theestimatedpatientresponsibilityforth
eprocedureis2,500annualdeductiblethathasnotbeenmet.Theestimatedpatientrespons
ibilityfortheprocedureis1,800. What is the most appropriate next step?
A. Schedule the procedure without further discussion
B. Notify the patient of the estimated financial responsibility prior to service
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C. Write off the deductible as charity care
D. Bill the full amount to the insurance company only
Rationale: Patient financial responsibility should be estimated and communicated
clearly before non-emergency services are rendered. This allows the patient to
make informed decisions about their care and financial obligations. Not discussing
the estimated cost (A) could lead to patient dissatisfaction and uncollectible
accounts. Writing off the deductible as charity care (C) requires proper financial
assistance screening and is not automatic based on an unmet deductible. Billing
only insurance (D) without informing the patient would leave the entire balance as
patient responsibility after claim processing, creating a surprise bill.
3. Under the Medicare Secondary Payer (MSP) rules, when a Medicare beneficiary
is involved in an auto accident and the auto insurer is expected to pay for medical
treatment, what action must the provider take before billing Medicare?
A. Bill Medicare immediately and let the two payers coordinate
B. First bill the auto insurer and submit documentation of that billing to
Medicare
C. Write off the charges as no-fault insurance liability
D. Request an Advance Beneficiary Notice (ABN) from the patient
Rationale: The Medicare Secondary Payer rules require that the primary payer
(auto insurer in no-fault or liability situations) be billed first. Medicare pays only
after the primary payer’s limits are exhausted or if the primary payer denies
payment. Billing Medicare immediately (A) would constitute improper billing.
Writing off charges (C) is inappropriate when there is viable primary coverage. An
ABN (D) is used for non-covered services, not for MSP coordination.
4. The patient registration area has a large sign-in sheet where patients write their
names and time of arrival. A patient complains that others can see their name and
reason for visit on the sheet. This practice most directly conflicts with which
provision of HIPAA?
A. The Security Rule for electronic protected health information (ePHI)
B. The Breach Notification Rule
C. The Privacy Rule’s minimum necessary standard
D. The Transactions and Code Sets Rule
Rationale: The HIPAA Privacy Rule requires covered entities to make reasonable
efforts to limit the use and disclosure of protected health information (PHI) to the
minimum necessary to accomplish the intended purpose. A sign-in sheet that
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displays identifiable patient information where others can view it violates the
minimum necessary standard by exposing PHI beyond what is needed for check-in.
The Security Rule (A) applies specifically to electronic PHI. The Breach
Notification Rule (B) applies after unauthorized access has occurred. The
Transactions and Code Sets Rule (D) governs electronic data interchange
standards, not privacy practices.
5. A Medicare beneficiary is admitted to an acute care hospital on a Friday. The
patient had outpatient laboratory services on Tuesday, an X-ray on Wednesday,
and an EKG on Thursday—all ordered by the same physician and related to the
admission diagnosis. Under the three-day DRG payment window rule, which of the
following statements is correct?
A. The hospital may bill all outpatient diagnostic services separately to Medicare
Part B
B. All outpatient diagnostic services provided within three days of admission
must be bundled into the inpatient DRG payment
C. Only services provided on the day of admission are bundled
D. The three-day window only applies to physician services, not hospital outpatient
services
*Rationale: The three-day DRG payment window rule (Section 1886(a)(4) of the
Social Security Act) requires hospitals to include all outpatient diagnostic services
provided within three calendar days prior to admission when billing under the
Inpatient Prospective Payment System (IPPS), provided the services are related to
the admission diagnosis. These services are bundled into the DRG payment and
cannot be billed separately to Part B. The rule applies to non-diagnostic services as
well under certain conditions. The correct answer captures the essence of bundling
within the window. Billing separately to Part B (A) would be improper. The
window extends beyond just the day of admission (C). The rule applies to hospital
outpatient services, not just physician services (D).
6. A collection agency under contract with a hospital calls a patient’s neighbor and
states, “I’m calling to collect a debt for Mercy Hospital. Do you know how I can
reach your neighbor, John Smith?” This action violates which federal law?
A. Fair Debt Collection Practices Act (FDCPA)
B. Health Insurance Portability and Accountability Act (HIPAA)
C. Emergency Medical Treatment and Labor Act (EMTALA)
D. False Claims Act (FCA)
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Rationale: The Fair Debt Collection Practices Act (FDCPA) prohibits debt
collectors from communicating with third parties about a consumer’s debt except
to obtain location information, and even that communication must not reveal that
the consumer owes a debt. The call to the neighbor disclosing the existence of a
debt violates the FDCPA. While HIPAA (B) also protects PHI, the FDCPA is the
primary law governing debt collection communications. EMTALA (C) governs
emergency medical screening and stabilization. The False Claims Act (D)
addresses fraudulent billing.
7. A patient presents to the emergency department (ED) with chest pain. The
hospital is an in-network provider for the patient’s commercial insurance plan, but
the on-call cardiologist is not in-network. The patient receives emergency
cardiology consultation and is admitted. Under the No Surprises Act, what is the
maximum amount the patient can be billed for the out-of-network cardiologist’s
services?
A. The full billed charges for the cardiologist’s services
B. The Medicare rate for cardiology consultation
C. The in-network cost-sharing amount that would apply if the cardiologist
were in-network
D. No payment is required because the patient did not sign a prior consent form
*Rationale: The No Surprises Act (effective January 1, 2022) protects patients
from surprise balance billing for emergency services provided by out-of-network
providers at in-network facilities. The patient cannot be billed more than the in-
network cost-sharing amount that would apply if the provider were in-network.
The provider and insurer must negotiate payment, or if they cannot agree, enter
independent dispute resolution. Billing the full billed charges (A) is prohibited.
The Medicare rate (B) may not apply to commercial plans. Consent forms (D) are
generally not required or valid for emergency services under the Act.*
8. A hospital’s chargemaster contains a line item for “surgical tray” with a charge
of 850.Uponaudit,thecosttothehospitalforthetrayis850.Uponaudit,thecosttothehospi
talforthetrayis50. Which of the following statements is most accurate regarding
this pricing practice?
A. The practice likely violates the False Claims Act if billed to government payers
B. Chargemaster prices are not required to be cost-based but must be
consistently applied and defensible
C. The charge must be reduced to a 200% markup maximum under federal
regulations
D. The hospital must disclose its markup percentage to all patients prior to service
HFMA CRCR {CERTIFIED REVENUE CYCLE
REPRESENTATIVE} COMPREHENSIVE ACTUAL
EXAM PREP 2026 ALL QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES ALREADY A GRADED WITH
EXPERT FEEDBACK | NEW AND REVISED
1. A hospital’s revenue cycle director notices a steady increase in days in accounts
receivable (A/R) over the past three months. Which of the following key
performance indicators (KPIs) would provide the most immediate insight into
whether the issue is related to claims processing delays?
A. Net collection rate
B. Claims denial rate
C. Bad debt percentage
D. Point-of-service collection rate
Rationale: A rising claims denial rate directly contributes to increased days in A/R
because denied claims require rework and resubmission before payment can be
received. The denial rate is a leading indicator of claims processing efficiency. Net
collection rate (A) measures overall effectiveness of collection efforts after all
adjustments, but it does not isolate the impact of denials. Bad debt percentage (C)
reflects accounts written off after exhaustive collection efforts, which is a lagging
indicator. Point-of-service collection rate (D) focuses on front-end collections and
does not address back-end claims processing delays.
2. During pre-registration for a scheduled outpatient surgery, the patient access
representative verifies insurance eligibility and learns the patient has
a 2,500annualdeductiblethathasnotbeenmet.Theestimatedpatientresponsibilityforth
eprocedureis2,500annualdeductiblethathasnotbeenmet.Theestimatedpatientrespons
ibilityfortheprocedureis1,800. What is the most appropriate next step?
A. Schedule the procedure without further discussion
B. Notify the patient of the estimated financial responsibility prior to service
,Page 2 of 74
C. Write off the deductible as charity care
D. Bill the full amount to the insurance company only
Rationale: Patient financial responsibility should be estimated and communicated
clearly before non-emergency services are rendered. This allows the patient to
make informed decisions about their care and financial obligations. Not discussing
the estimated cost (A) could lead to patient dissatisfaction and uncollectible
accounts. Writing off the deductible as charity care (C) requires proper financial
assistance screening and is not automatic based on an unmet deductible. Billing
only insurance (D) without informing the patient would leave the entire balance as
patient responsibility after claim processing, creating a surprise bill.
3. Under the Medicare Secondary Payer (MSP) rules, when a Medicare beneficiary
is involved in an auto accident and the auto insurer is expected to pay for medical
treatment, what action must the provider take before billing Medicare?
A. Bill Medicare immediately and let the two payers coordinate
B. First bill the auto insurer and submit documentation of that billing to
Medicare
C. Write off the charges as no-fault insurance liability
D. Request an Advance Beneficiary Notice (ABN) from the patient
Rationale: The Medicare Secondary Payer rules require that the primary payer
(auto insurer in no-fault or liability situations) be billed first. Medicare pays only
after the primary payer’s limits are exhausted or if the primary payer denies
payment. Billing Medicare immediately (A) would constitute improper billing.
Writing off charges (C) is inappropriate when there is viable primary coverage. An
ABN (D) is used for non-covered services, not for MSP coordination.
4. The patient registration area has a large sign-in sheet where patients write their
names and time of arrival. A patient complains that others can see their name and
reason for visit on the sheet. This practice most directly conflicts with which
provision of HIPAA?
A. The Security Rule for electronic protected health information (ePHI)
B. The Breach Notification Rule
C. The Privacy Rule’s minimum necessary standard
D. The Transactions and Code Sets Rule
Rationale: The HIPAA Privacy Rule requires covered entities to make reasonable
efforts to limit the use and disclosure of protected health information (PHI) to the
minimum necessary to accomplish the intended purpose. A sign-in sheet that
,Page 3 of 74
displays identifiable patient information where others can view it violates the
minimum necessary standard by exposing PHI beyond what is needed for check-in.
The Security Rule (A) applies specifically to electronic PHI. The Breach
Notification Rule (B) applies after unauthorized access has occurred. The
Transactions and Code Sets Rule (D) governs electronic data interchange
standards, not privacy practices.
5. A Medicare beneficiary is admitted to an acute care hospital on a Friday. The
patient had outpatient laboratory services on Tuesday, an X-ray on Wednesday,
and an EKG on Thursday—all ordered by the same physician and related to the
admission diagnosis. Under the three-day DRG payment window rule, which of the
following statements is correct?
A. The hospital may bill all outpatient diagnostic services separately to Medicare
Part B
B. All outpatient diagnostic services provided within three days of admission
must be bundled into the inpatient DRG payment
C. Only services provided on the day of admission are bundled
D. The three-day window only applies to physician services, not hospital outpatient
services
*Rationale: The three-day DRG payment window rule (Section 1886(a)(4) of the
Social Security Act) requires hospitals to include all outpatient diagnostic services
provided within three calendar days prior to admission when billing under the
Inpatient Prospective Payment System (IPPS), provided the services are related to
the admission diagnosis. These services are bundled into the DRG payment and
cannot be billed separately to Part B. The rule applies to non-diagnostic services as
well under certain conditions. The correct answer captures the essence of bundling
within the window. Billing separately to Part B (A) would be improper. The
window extends beyond just the day of admission (C). The rule applies to hospital
outpatient services, not just physician services (D).
6. A collection agency under contract with a hospital calls a patient’s neighbor and
states, “I’m calling to collect a debt for Mercy Hospital. Do you know how I can
reach your neighbor, John Smith?” This action violates which federal law?
A. Fair Debt Collection Practices Act (FDCPA)
B. Health Insurance Portability and Accountability Act (HIPAA)
C. Emergency Medical Treatment and Labor Act (EMTALA)
D. False Claims Act (FCA)
, Page 4 of 74
Rationale: The Fair Debt Collection Practices Act (FDCPA) prohibits debt
collectors from communicating with third parties about a consumer’s debt except
to obtain location information, and even that communication must not reveal that
the consumer owes a debt. The call to the neighbor disclosing the existence of a
debt violates the FDCPA. While HIPAA (B) also protects PHI, the FDCPA is the
primary law governing debt collection communications. EMTALA (C) governs
emergency medical screening and stabilization. The False Claims Act (D)
addresses fraudulent billing.
7. A patient presents to the emergency department (ED) with chest pain. The
hospital is an in-network provider for the patient’s commercial insurance plan, but
the on-call cardiologist is not in-network. The patient receives emergency
cardiology consultation and is admitted. Under the No Surprises Act, what is the
maximum amount the patient can be billed for the out-of-network cardiologist’s
services?
A. The full billed charges for the cardiologist’s services
B. The Medicare rate for cardiology consultation
C. The in-network cost-sharing amount that would apply if the cardiologist
were in-network
D. No payment is required because the patient did not sign a prior consent form
*Rationale: The No Surprises Act (effective January 1, 2022) protects patients
from surprise balance billing for emergency services provided by out-of-network
providers at in-network facilities. The patient cannot be billed more than the in-
network cost-sharing amount that would apply if the provider were in-network.
The provider and insurer must negotiate payment, or if they cannot agree, enter
independent dispute resolution. Billing the full billed charges (A) is prohibited.
The Medicare rate (B) may not apply to commercial plans. Consent forms (D) are
generally not required or valid for emergency services under the Act.*
8. A hospital’s chargemaster contains a line item for “surgical tray” with a charge
of 850.Uponaudit,thecosttothehospitalforthetrayis850.Uponaudit,thecosttothehospi
talforthetrayis50. Which of the following statements is most accurate regarding
this pricing practice?
A. The practice likely violates the False Claims Act if billed to government payers
B. Chargemaster prices are not required to be cost-based but must be
consistently applied and defensible
C. The charge must be reduced to a 200% markup maximum under federal
regulations
D. The hospital must disclose its markup percentage to all patients prior to service
