CRCR In-class activity Classic Live

CRCR In-class activity (2023) What do Case Managers do? - Monitor high resource cases to ensure effective utilization What is HIM responsible for? - all pt medical records: transcribe, coding, release to biling, answer requests for documentation What is utilization management responsible for? - manage cases: services correct, on time What are the three types of utilization review? - Prospective, Concurrent, Retrospective Where can home health services be offered? - Home, Assist Living, neighbors: just not SNF nor Hospital To receive -Care payments, what must a SNF have when receiving a pt from a hosp? - A transfer agreement approved by -Care. Can a home health agency employ another agency to provide services? - Yes, so long as at least one employee of the original agency provides care. What is the Net Collection Rate? - how much cash was collected as a % of available to collect? What is the Net Collection Rate benchmark? - 95% What is the benchmark for denials - 2% on first submission Formual for cost to collect - total PFS expenses/gross pt care collections What is the benchmark for cost to collect - 2.25% What % of the UB-04 source of data is from pt access? - 40% What % of the UB-04 source of data is from service depts? - 11% What % of the UB-04 source of data is from HIM? - 20% What % of the UB-04 source of data is from billing? - 20% What % of the UB-04 source of data is not used? - 9% What % of the CMS 1500 source of data is from pt access? - 53% What % of the CMS 1500 source of data is from service? - 14% What % of the CMS 1500 source of data is from HIM - 7% What % of the CMS 1500 source of data is from billing? - 26% From whom is the UB-04 directed? - institutional: hospitals, SNF, hospice From whom is the CMS 1500? - non-institutional: physicians, DME In the FDCA, what is Title I - Truth in Lending Act What is the Truth in Lending Act - 5 points must be triggered (such as interest will be charged), then must disclose APR, total payments, late payment charges, etc. What are the penalties for violating the FDCA? - creditors can be sued Who enforces the FDCA for hospitals? - FTC In the FDCA, what is Title III - limits garnishments In the FDCA, what is Title IV - Fair Credit Reporting Act What is the Fair Credit Reporting Act? - provides consumer rights in reporting loans Are there rules for how a debt collector communicates with debtor? - Yes, eg no profane language, can't contact before 8 AM Is a newborn a scheduled or unscheduled pt - unscheduled What are the three types of pt access incoming to a HCO? - scheduled, unscheduled, recurring What is LCD - local coverage determinants, in absence of NCD, LCD dtermines whether -Care will pay for an item or service What is NCD - national coverage determinants:' nationwide determination of whether Medicare will pay for an item or service What % of pts should be pre-registered of all scheduled pts? - 98% What is the code for HIPAA transaction set for HC eligibility and benefit responses - 270 outgoing 271 response What are some payer data elements needed to process payment? - policy type, covered persons, mail address, cvr type (HMO), deductible What is an PPO - closest to indemnity plan, only preferred doctors in network get contracted prices What is an EPO - exclusive provider - limits services to only EP What is POS - point of service - if doc makes referral out, plan will pay, if pt requests out of service, pt pays What is CDHP - consumer directed healthplan, often with a HSA What is the % discount model in MCO - a % is discounted What is the DRG model in MCO - pymt based on predetermined fixed amount What is the APG model in MCO - divides outpt services into 600 procedural groups, each APG assigned a relative payment weight What is a case rate - pt's condition forms basis for payment for all services What is stop loss - plan covers 80% of charges to 100%, stop loss is plan covers 50% of charges $120k What are some managed care requirments? - pre-certification/pre-authorization, referral (PCP-specialist), notification - providers notify payer pt is requesting service, days approval, continued stay review, site of service limitations (eg only colonosco as outpt) What are some concerns with EMTALA - sign posted on walls, no prior authorization, women in active labor must be assisted thru delivery, on-call MD must respond, no dumping, no transfer (unless cannot provide service), must do mental health screening, must keep pt log