CHAPTER 6: BILLING AND REVENUE
CYCLE EXAM QUESTIONS WITH
ACTUAL ANSWERS
The patient experience can be affected throughout a patient's health care journey,
including the revenue cycle. What are some of the actions that impact the patient
experience related to billing? - ANSWERSCollecting precise demographic information,
accurate data-entry, verifying coding and timely billing all impact the patient experience.
Complete and accurate claims promote a healthy revenue cycle and build patient trust
and confidence in the organization
Precertification - ANSWERSFinding out if the service is covered by the patient's plan
Preauthorization - ANSWERSDetermining the payer's reimbursement amount for the
service
Preauthorization - ANSWERSFinding out if the payer considers a service medically
necessary based in the patient's specific condition
Describe when the revenue cycle starts and when it ends - ANSWERSThe revenue
cycle begins with the patient registration and scheduling and ends when the claim is
paid in full. The revenue cycle maintains the financial stability of the health care
organization
Briefly describe how practice management systems impact the healthcare organization -
ANSWERSPractice management systems(PMS) are an efficient way to boost
productivity and streamline with automation patient A/R controls, appointment
scheduling, charge capture, generating financial reports and patient statements. They
are efficient examples of how to utilize the PMS system to remain sustainable and
improve patient outcomes.
Briefly describe charge capture and coding as it applies to the revenue cycle -
ANSWERSthe process of entering the CPT, HCPCS, and ICD-10-CM codes associated
with the patient encounter to prepare the claim for submission to the insurance payer.
Reimbursement for services rendered are not paid unless charges are entered into
PMS, coded correctly and submitted to the insurance payer
Why might a preauthorization be necessary prior to performing a procedure? -
ANSWERSThe insurance payer does not want to be responsible for reimbursement on
services that may not be medically necessary. The CMAA will contact the payer and
, provide patient health history information to describe the medical necessity of the
service
A patient is scheduled for an appointment tomorrow, and the CMAA notices the
authorization number has expired and must be extended or a new authorization number
obtained. Which of the following steps of the revenue cycle involves obtaining and
verifying prior authorizations for certain procedures?
A. Patient check-in
B. Health care encounter and documentation
C. Utilization management review
D. Payer Adjudication - ANSWERSC. Utilization management review
Describe when a referral would be needed for patient care - ANSWERSFor patient care
when a patient is in need of a more specialized care and treatment. For example, when
a primary care provider refers a patient to the cardiologist for management of heart
disease.
Captitation - ANSWERSA managed care method of monthly payments to the provider
based on the number of enrolled patients, regardless of how many encounters a patient
may have during the month
Carved out - ANSWERSMedical services not included in the contracted capitation rate.
These services may be billed separately
Typical reasons for claim rejections include: - ANSWERSIncorrect, invalid or non
specific diagnosis codes, invalid or incorrect procedure codes, incorrect or missing
modifiers, mismatched place of service to type of service, missing provider or
organization NPI number
Describe the components of a daily batch within the PMS - ANSWERSA collection of all
transactions performed throughout the day. This includes posting charges for the
encounter and payments from the patient and payer along with any adjustments made
per payer/provider contract
When posting the daily batch for the day's work, it is discovered that the payments
entered in the PMS and the payments showing in the journal do not match. How can
this issue be resolved prior to closing the daily batch? - ANSWERSIt will be necessary
to review the payments posted in the PMS for each patient payment and the payments
from the insurance payer and compare each payment to the daily ledger and the pay
remittance advice
Value-based care model - ANSWERSA P4P program that rewards the provider with
incentive payments for meeting defined program performance standards.
CYCLE EXAM QUESTIONS WITH
ACTUAL ANSWERS
The patient experience can be affected throughout a patient's health care journey,
including the revenue cycle. What are some of the actions that impact the patient
experience related to billing? - ANSWERSCollecting precise demographic information,
accurate data-entry, verifying coding and timely billing all impact the patient experience.
Complete and accurate claims promote a healthy revenue cycle and build patient trust
and confidence in the organization
Precertification - ANSWERSFinding out if the service is covered by the patient's plan
Preauthorization - ANSWERSDetermining the payer's reimbursement amount for the
service
Preauthorization - ANSWERSFinding out if the payer considers a service medically
necessary based in the patient's specific condition
Describe when the revenue cycle starts and when it ends - ANSWERSThe revenue
cycle begins with the patient registration and scheduling and ends when the claim is
paid in full. The revenue cycle maintains the financial stability of the health care
organization
Briefly describe how practice management systems impact the healthcare organization -
ANSWERSPractice management systems(PMS) are an efficient way to boost
productivity and streamline with automation patient A/R controls, appointment
scheduling, charge capture, generating financial reports and patient statements. They
are efficient examples of how to utilize the PMS system to remain sustainable and
improve patient outcomes.
Briefly describe charge capture and coding as it applies to the revenue cycle -
ANSWERSthe process of entering the CPT, HCPCS, and ICD-10-CM codes associated
with the patient encounter to prepare the claim for submission to the insurance payer.
Reimbursement for services rendered are not paid unless charges are entered into
PMS, coded correctly and submitted to the insurance payer
Why might a preauthorization be necessary prior to performing a procedure? -
ANSWERSThe insurance payer does not want to be responsible for reimbursement on
services that may not be medically necessary. The CMAA will contact the payer and
, provide patient health history information to describe the medical necessity of the
service
A patient is scheduled for an appointment tomorrow, and the CMAA notices the
authorization number has expired and must be extended or a new authorization number
obtained. Which of the following steps of the revenue cycle involves obtaining and
verifying prior authorizations for certain procedures?
A. Patient check-in
B. Health care encounter and documentation
C. Utilization management review
D. Payer Adjudication - ANSWERSC. Utilization management review
Describe when a referral would be needed for patient care - ANSWERSFor patient care
when a patient is in need of a more specialized care and treatment. For example, when
a primary care provider refers a patient to the cardiologist for management of heart
disease.
Captitation - ANSWERSA managed care method of monthly payments to the provider
based on the number of enrolled patients, regardless of how many encounters a patient
may have during the month
Carved out - ANSWERSMedical services not included in the contracted capitation rate.
These services may be billed separately
Typical reasons for claim rejections include: - ANSWERSIncorrect, invalid or non
specific diagnosis codes, invalid or incorrect procedure codes, incorrect or missing
modifiers, mismatched place of service to type of service, missing provider or
organization NPI number
Describe the components of a daily batch within the PMS - ANSWERSA collection of all
transactions performed throughout the day. This includes posting charges for the
encounter and payments from the patient and payer along with any adjustments made
per payer/provider contract
When posting the daily batch for the day's work, it is discovered that the payments
entered in the PMS and the payments showing in the journal do not match. How can
this issue be resolved prior to closing the daily batch? - ANSWERSIt will be necessary
to review the payments posted in the PMS for each patient payment and the payments
from the insurance payer and compare each payment to the daily ledger and the pay
remittance advice
Value-based care model - ANSWERSA P4P program that rewards the provider with
incentive payments for meeting defined program performance standards.
