CRCR ACTUAL ALL FINAL ANSWERS AND
QUESTIONS SET A+
✔✔Same-day admission - ✔✔A cost containment practice that reduces a surgical
patient's inpatient stay by requiring that pre-procedure testing and preparation are
completed on an outpatient basis and the patient is admitted the same day as the
procedure
✔✔Self-insured - ✔✔Large employers who assume direct responsibility or risk for
paying employees' healthcare without purchasing health insurance
✔✔Subrogation - ✔✔Seeking, by legal or administrative means, reimbursement from
another party that is primarily responsible for a patient's medical expenses
✔✔Subscriber - ✔✔An employer, a union, or an association that contracts with an
insurance company for the healthcare plan it offers to eligible employees
✔✔Sub-specialist - ✔✔A healthcare professional who is recognized to have expertise in
a specialty of medicine or surgery
✔✔Third-part administrator (TPA) - ✔✔Provides services to employers or insurance
companies for utilization review, claims payment and benefit design
✔✔Third-party reimbursement - ✔✔A general term used for the healthcare benefit
payments - used to identify that for benefit plans there are three parties in the
transaction
✔✔Usual, customary, and reasonable (UCR) - ✔✔Health insurance plan reimbursement
methodology that limits payment to the lower billed charges, the provider's customary
charge, or the prevailing charge for the service in the community
✔✔Utilization review - ✔✔Review conducted by professional healthcare personnel of
the appropriateness of, quality of, and need for healthcare services provided to patients
, ✔✔Charge - ✔✔The dollar amount a provider sets for services rendered before
negotiating any discounts. The charge can be different from the amount paid
✔✔Cost - ✔✔The definition of cost varies by party incurring the expense
✔✔Price - ✔✔the total amount a provider expects to be paid by payers and patients for
healthcare services
✔✔Care purchaser - ✔✔Individual or entity that contributes to the purchase of
healthcare services
✔✔Payer - ✔✔An organization that negotiates or sets rates for provider services,
collects revenue through premium payments or tax dollars, processes provider claims
for service, and pays provider claims using collected premium or tax revenues
✔✔Provider - ✔✔An entity, organization, or individual that furnishes a healthcare
service
✔✔Out of pocket payment - ✔✔The portion of the total payment for medical services
and treatment for which the patient is responsible, including copayments, coinsurance,
and deductibles
✔✔Price transparency - ✔✔In health care, readily available information on the price of
healthcare services that, together, with other information helps define the value of those
services and enables patients and other care purchasers to identify, compare, and
choose providers that offer the desired level of value
✔✔Value - ✔✔The quality of a healthcare service in relation to the total price paid for
the service by care purchasers
✔✔What areas does the code of conduct typically focus on? - ✔✔Human resources.
Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest.
Laws/regulations
✔✔FERA - ✔✔Fraud Enforcement and Recovery act
✔✔ESRD - ✔✔End-stage renal disease. The patient has permanent kidney failure, is
covered by a GHP, and has not yet completed the 30-month coordination period
✔✔What is the purpose of a compliance program? - ✔✔Mitigate potential fraud and
abuse in the industry-specific key risk areas
✔✔What is important about an effective corporate compliance program? - ✔✔A
program that embodies many elements to create a program that is transparent, clearly
QUESTIONS SET A+
✔✔Same-day admission - ✔✔A cost containment practice that reduces a surgical
patient's inpatient stay by requiring that pre-procedure testing and preparation are
completed on an outpatient basis and the patient is admitted the same day as the
procedure
✔✔Self-insured - ✔✔Large employers who assume direct responsibility or risk for
paying employees' healthcare without purchasing health insurance
✔✔Subrogation - ✔✔Seeking, by legal or administrative means, reimbursement from
another party that is primarily responsible for a patient's medical expenses
✔✔Subscriber - ✔✔An employer, a union, or an association that contracts with an
insurance company for the healthcare plan it offers to eligible employees
✔✔Sub-specialist - ✔✔A healthcare professional who is recognized to have expertise in
a specialty of medicine or surgery
✔✔Third-part administrator (TPA) - ✔✔Provides services to employers or insurance
companies for utilization review, claims payment and benefit design
✔✔Third-party reimbursement - ✔✔A general term used for the healthcare benefit
payments - used to identify that for benefit plans there are three parties in the
transaction
✔✔Usual, customary, and reasonable (UCR) - ✔✔Health insurance plan reimbursement
methodology that limits payment to the lower billed charges, the provider's customary
charge, or the prevailing charge for the service in the community
✔✔Utilization review - ✔✔Review conducted by professional healthcare personnel of
the appropriateness of, quality of, and need for healthcare services provided to patients
, ✔✔Charge - ✔✔The dollar amount a provider sets for services rendered before
negotiating any discounts. The charge can be different from the amount paid
✔✔Cost - ✔✔The definition of cost varies by party incurring the expense
✔✔Price - ✔✔the total amount a provider expects to be paid by payers and patients for
healthcare services
✔✔Care purchaser - ✔✔Individual or entity that contributes to the purchase of
healthcare services
✔✔Payer - ✔✔An organization that negotiates or sets rates for provider services,
collects revenue through premium payments or tax dollars, processes provider claims
for service, and pays provider claims using collected premium or tax revenues
✔✔Provider - ✔✔An entity, organization, or individual that furnishes a healthcare
service
✔✔Out of pocket payment - ✔✔The portion of the total payment for medical services
and treatment for which the patient is responsible, including copayments, coinsurance,
and deductibles
✔✔Price transparency - ✔✔In health care, readily available information on the price of
healthcare services that, together, with other information helps define the value of those
services and enables patients and other care purchasers to identify, compare, and
choose providers that offer the desired level of value
✔✔Value - ✔✔The quality of a healthcare service in relation to the total price paid for
the service by care purchasers
✔✔What areas does the code of conduct typically focus on? - ✔✔Human resources.
Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest.
Laws/regulations
✔✔FERA - ✔✔Fraud Enforcement and Recovery act
✔✔ESRD - ✔✔End-stage renal disease. The patient has permanent kidney failure, is
covered by a GHP, and has not yet completed the 30-month coordination period
✔✔What is the purpose of a compliance program? - ✔✔Mitigate potential fraud and
abuse in the industry-specific key risk areas
✔✔What is important about an effective corporate compliance program? - ✔✔A
program that embodies many elements to create a program that is transparent, clearly
