FINAL HIM REVENUE CYCLE
MANAGEMENT QUESTIONS AND
ANSWERS 100% CORRECT
National health service model - ANSWER-In this model, the government is the only
payer that funds universal healthcare coverage through taxes
Private health insurance model - ANSWER-In this healthcare delivery model, the
insurance company determines that contribution amount that is not based on the
policyholder's income
Social insurance model - ANSWER-In this healthcare delivery model, employees and
employers contribute an income based amount of money to funds that are regulated by
the government
Increased spending - ANSWER-The US healthcare sector represents a significant
portion of the US economy. The trend of _______ spending on healthcare has been
consistent for more than a decade
Patient; employer - ANSWER-An employee paying for 40 percent of the insurance
premium through payroll processing is an example of a transaction between _____ and
______.
Provider; third party payer - ANSWER-A physician office is submitting an invoice (claim)
for payment when the patient has health insurance is an example of a transaction
between ____ and _______.
To assure that the pool is large enough to pay losses for the entire group - ANSWER-
Why do health insurers pool premium payments for all the insureds in a group and use
actuarial data to calculate the group's premiums?
Reduction of a person's or group's exposure to risk for unknown healthcare costs by the
assumption of that risk by an entity - ANSWER-In the US, what is health insurance?
Clean, complete, compliant - ANSWER-The goal of revenue integrity is to produce a
claim that is _______
Multidisciplinary model - ANSWER-Successful RCM programs use this type of
approach, which promotes collaboration among various clinical departments and
emphasizes an education strategy for all members
, Risk pool is a group of entities that can include individuals, employers, or associations,
whose healthcare costs are combined to evaluate the financial history and estimate
future costs - ANSWER-Define the term risk pool
Covered conditions are the health conditions, illnesses, injuries, diseases or symptoms
such as diabetes, that the health insurance will reimburse for treatment that attempts to
maintain, control, or cure said conditions. Covered services are the healthcare services
such as yearly wellness check, that the insurance company will pay as outlined in the
healthcare plan - ANSWER-What is the relationship between covered conditions and
covered services?
Insured, certificate holder, and member - ANSWER-LIst 3 synonyms for policy holder
The deductible is the amount of money that the policyholder must pay before the health
insurance will assume its share of liability for the remaining charges or covered
expenses - ANSWER-What is the definition of deductible
The summary of benefits and coverage is a document that explains in plain language
the information about a health insurance company's benefits and its coverage or health
services. This document is aimed to provide additional information about the
policyholder's coverage. - ANSWER-What is the purpose of the Summary of Benefits
and Coverage?
1. The selection of providers, where senior clinicians and upper echelons of the plan
select providers using pre-established procedures and standards
2. The health of populations, where emphasis is on the health pf the entire population
that the MCO serves
3. The use of care management tools, such as coordination of care, disease
management and the application of evidence based clinical practice guidelines. -
ANSWER-Define at least three ways in which MCOs work towards their goals of quality
patient care
Step 1: clinical review by a licensed health proffesional to review established criteria
Step 2: Peer clinical review by a peer physician who is qualified to render clinical
opinions
Step 3: Appeals consideration/ decision by a qualified expert clinician in the same
specialty. The clinician is not involved in the initial decision but is qualified to render
clinical opinions. - ANSWER-Name the three steps in utilization review
CPOE - ANSWER-Which charge capture strategy allows physicians and other providers
to order services with a computerized system?
Charge - ANSWER-The dollar amount the facility actually bills for the services it
provides is known as
MANAGEMENT QUESTIONS AND
ANSWERS 100% CORRECT
National health service model - ANSWER-In this model, the government is the only
payer that funds universal healthcare coverage through taxes
Private health insurance model - ANSWER-In this healthcare delivery model, the
insurance company determines that contribution amount that is not based on the
policyholder's income
Social insurance model - ANSWER-In this healthcare delivery model, employees and
employers contribute an income based amount of money to funds that are regulated by
the government
Increased spending - ANSWER-The US healthcare sector represents a significant
portion of the US economy. The trend of _______ spending on healthcare has been
consistent for more than a decade
Patient; employer - ANSWER-An employee paying for 40 percent of the insurance
premium through payroll processing is an example of a transaction between _____ and
______.
Provider; third party payer - ANSWER-A physician office is submitting an invoice (claim)
for payment when the patient has health insurance is an example of a transaction
between ____ and _______.
To assure that the pool is large enough to pay losses for the entire group - ANSWER-
Why do health insurers pool premium payments for all the insureds in a group and use
actuarial data to calculate the group's premiums?
Reduction of a person's or group's exposure to risk for unknown healthcare costs by the
assumption of that risk by an entity - ANSWER-In the US, what is health insurance?
Clean, complete, compliant - ANSWER-The goal of revenue integrity is to produce a
claim that is _______
Multidisciplinary model - ANSWER-Successful RCM programs use this type of
approach, which promotes collaboration among various clinical departments and
emphasizes an education strategy for all members
, Risk pool is a group of entities that can include individuals, employers, or associations,
whose healthcare costs are combined to evaluate the financial history and estimate
future costs - ANSWER-Define the term risk pool
Covered conditions are the health conditions, illnesses, injuries, diseases or symptoms
such as diabetes, that the health insurance will reimburse for treatment that attempts to
maintain, control, or cure said conditions. Covered services are the healthcare services
such as yearly wellness check, that the insurance company will pay as outlined in the
healthcare plan - ANSWER-What is the relationship between covered conditions and
covered services?
Insured, certificate holder, and member - ANSWER-LIst 3 synonyms for policy holder
The deductible is the amount of money that the policyholder must pay before the health
insurance will assume its share of liability for the remaining charges or covered
expenses - ANSWER-What is the definition of deductible
The summary of benefits and coverage is a document that explains in plain language
the information about a health insurance company's benefits and its coverage or health
services. This document is aimed to provide additional information about the
policyholder's coverage. - ANSWER-What is the purpose of the Summary of Benefits
and Coverage?
1. The selection of providers, where senior clinicians and upper echelons of the plan
select providers using pre-established procedures and standards
2. The health of populations, where emphasis is on the health pf the entire population
that the MCO serves
3. The use of care management tools, such as coordination of care, disease
management and the application of evidence based clinical practice guidelines. -
ANSWER-Define at least three ways in which MCOs work towards their goals of quality
patient care
Step 1: clinical review by a licensed health proffesional to review established criteria
Step 2: Peer clinical review by a peer physician who is qualified to render clinical
opinions
Step 3: Appeals consideration/ decision by a qualified expert clinician in the same
specialty. The clinician is not involved in the initial decision but is qualified to render
clinical opinions. - ANSWER-Name the three steps in utilization review
CPOE - ANSWER-Which charge capture strategy allows physicians and other providers
to order services with a computerized system?
Charge - ANSWER-The dollar amount the facility actually bills for the services it
provides is known as
