CRCR EXAM MULTIPLE CHOICE,
Questions and Answers CRCR
Discounted fee-for-service -
✔️A reimbursement methodology whereby a provider agrees to provide service on a
fee for service basis, but the fees are discounted by certain packages
Eligibility -
✔️Patient status regarding coverage for healthcare insurance benefits
First dollar coverage -
✔️A healthcare insurance policy that has no deductible and covers the first dollar of
an insured's expenses
Gatekeeping -
✔️A concept wherein the primary care physician provides all primary patient care
and coordinates all diagnostic testing and specialty referrals required for a patient's
medical care
Health plan -
,✔️an insurance company that provides for the delivery or payment of healthcare
services
Indemnity insurance -
✔️negotiated healthcare coverage within a framework of fee schedules, limitations,
and exclusions that is offered by insurance companies or benevolent associations
Medically necessary -
✔️Healthcare services that are required to preserve or maintain a person's health
status in accordance with medical practice standards
Out-of-area benefits -
✔️healthcare plan coverage allowed to covered persons for emergency situations
outside of the prescribed geographic area of the HMO
Out-of-pocket payments -
✔️Cash payments made by the insured for services not covered by the health
insurance plan
Pre-admission review -
✔️the practice of reviewing requests for inpatient admission before the patient is
admitted to ensure that the admission is medically necesary
Pre-existing condition limitation -
✔️A restriction on payments for charges directly resulting from a pre-existing health
conditions
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 articulated and emphasized at all employee levels as a
seriously held personal and organizational responsibility, one that relies on full
communication inside and outside the organization
What is a CCO -
✔️Chief compliance officer - they typically report directly to the board
of directors/trustees as well as the chief executive officer, and has
limited responsibilities for other operational aspects of the organization
What are the situations where another payer may be completely responsible for
payment? -
✔️Work-related accidents, black lung program services, patient is enrolled in
Medicare Advantage, Federal grant programs
Under Medicare rules, certain outpatient services that are provided within three days
of the admission date, by hospitals or by entities owned or controlled by hospitals,
must be billed as part of an inpatient stay. - ✔️TRUE
The OIG has issued compliance guidance/model compliance plans for all of the
following entities: -
✔️hospices. physician practices. ambulance providers
Providers who are found to be in violation of CMS regulations are subject to: -
✔️Corporate integrity agreements
What MSP situation requires LGHP -
✔️Disability
The disadvantages of outsourcing include all of the following EXCEPT: a)
The impact of customer service or patient relations
b) The impact of loss of direct control of accounts receivable services
c) Increased costs due to vendor ineffectiveness
d) Reduced internal staffing costs and a reliance on outsourced staff -
✔️D
Questions and Answers CRCR
Discounted fee-for-service -
✔️A reimbursement methodology whereby a provider agrees to provide service on a
fee for service basis, but the fees are discounted by certain packages
Eligibility -
✔️Patient status regarding coverage for healthcare insurance benefits
First dollar coverage -
✔️A healthcare insurance policy that has no deductible and covers the first dollar of
an insured's expenses
Gatekeeping -
✔️A concept wherein the primary care physician provides all primary patient care
and coordinates all diagnostic testing and specialty referrals required for a patient's
medical care
Health plan -
,✔️an insurance company that provides for the delivery or payment of healthcare
services
Indemnity insurance -
✔️negotiated healthcare coverage within a framework of fee schedules, limitations,
and exclusions that is offered by insurance companies or benevolent associations
Medically necessary -
✔️Healthcare services that are required to preserve or maintain a person's health
status in accordance with medical practice standards
Out-of-area benefits -
✔️healthcare plan coverage allowed to covered persons for emergency situations
outside of the prescribed geographic area of the HMO
Out-of-pocket payments -
✔️Cash payments made by the insured for services not covered by the health
insurance plan
Pre-admission review -
✔️the practice of reviewing requests for inpatient admission before the patient is
admitted to ensure that the admission is medically necesary
Pre-existing condition limitation -
✔️A restriction on payments for charges directly resulting from a pre-existing health
conditions
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 articulated and emphasized at all employee levels as a
seriously held personal and organizational responsibility, one that relies on full
communication inside and outside the organization
What is a CCO -
✔️Chief compliance officer - they typically report directly to the board
of directors/trustees as well as the chief executive officer, and has
limited responsibilities for other operational aspects of the organization
What are the situations where another payer may be completely responsible for
payment? -
✔️Work-related accidents, black lung program services, patient is enrolled in
Medicare Advantage, Federal grant programs
Under Medicare rules, certain outpatient services that are provided within three days
of the admission date, by hospitals or by entities owned or controlled by hospitals,
must be billed as part of an inpatient stay. - ✔️TRUE
The OIG has issued compliance guidance/model compliance plans for all of the
following entities: -
✔️hospices. physician practices. ambulance providers
Providers who are found to be in violation of CMS regulations are subject to: -
✔️Corporate integrity agreements
What MSP situation requires LGHP -
✔️Disability
The disadvantages of outsourcing include all of the following EXCEPT: a)
The impact of customer service or patient relations
b) The impact of loss of direct control of accounts receivable services
c) Increased costs due to vendor ineffectiveness
d) Reduced internal staffing costs and a reliance on outsourced staff -
✔️D
