HFMA CRCR exam 2023 with 100% correct answers GRADED A/LATEST VERSIONThrough what document does a hospital establish compliance standards? Ans code of conductWhat is the purpose OIG work plant? Ans Identify Acceptable compliance programs in various provid

HFMA CRCR exam 2023 with 100% correct answers GRADED A/LATEST VERSIONThrough what document does a hospital establish compliance standards? Ans code of conductWhat is the purpose OIG work plant? Ans Identify Acceptable compliance programs in various provider settingIf a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule?Ans Non-diagnostic service provided on Tuesday through FridayWhat does a modifier allow a provider to do? Ans Report a specific circumstance that affected a procedure or service without changing the code or its definitionIF outpatient diagnostic services are provided within three days of the admission of a Medicare beneficiary to an IPPS (Inpatient Prospective Payment System) hospital, what must happen to these charges AnsThey must be billed separately to the part B Carrierwhat is a recurring or series registration? Ans One registration record is created for multiple days of serviceWhat are nonemergency patients who come for service without prior notification to the provider called?Ans Unscheduled patientsWhich of the following statement apply to the observation patient type? Ans It is used to evaluate the need for an inpatient admissionwhich services are hospice programs required to provide around the clock patient Ans Physician, Nursing, PharmacyScheduler instructions are used to prompt the scheduler to do what? Ans Complete the scheduling process correctly based on service requesteThe Time needed to prepare the patient before service is the difference between the patients arrival time and which of the following?Ans Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: Ans Documentation of the medical necessity for the testWhat is the advantage of a pre-registration program Ans It reduces processing times at the time of serviceWhat date are required to establish a new MPI(Master patient Index) entry Ans The responsible party's full legal name, date of birth, and social security numberWhich of the following statements is true about third-party payments? AnsThe payments are received by the provider from the payer responsible for reimbursing the provider for the patient's covered services.Which provision protects the patient from medical expenses that exceed the pre-set level Ans stop losswhat documentation must a primary care physician send to HMO patient to authorize a visit to a specialist for additional testing or care? AnsReferralUnder EMTALA (Emergency Medical Treatment and Labor Act) regulations, the provider may not ask about a patient's insurance information if it would delay what?AnsMedical screening and stabilizing treatmentWhich of the following is a step in the discharge process? Ans Have a case management service complete the discharge planThe hospital has a APC based contract for the payment of outpatient services. Total anticipated charges for the visit are $2,380. The approved APC payment rate is $780. Where will the patients benefit package be applied? AnsTo the approved APC payment rateA patient has met the $200 individual deductible and $900 of the $1000 co-insurance responsibility. The co-insurance rate is 20%. The estimated insurance plan responsibility is $1975.00. What amount of coinsurance is due from the patient?Ans When is a patient considered to be medically indigent? Ans The patient's outstanding medical bills exceed a defined dollar amount or percentage of assets.What patient assets are considered in the financial assistance application? Ans Sources of readily available funds , vehicles, campers, boats and saving accountsIf the patient cannot agree to payment arrangements, What is the next option? Ans Warn the patient that unpaid accounts are placed with collection agencies for further processingWhat core financial activities are resolved within patient access? Ans scheduling , pre-registration, insurance verification and managed care processingWhat is an unscheduled direct admission? Ans A patient who arrives at the hospital via ambulance for treatment in the emergency departmentWhen is it not appropriate to use observation status? Ans As a substitute for an inpatient admissionPatients who require periodic skilled nursing or therapeutic care receive services from what type of program? AnsHome health agencyEvery patient who is new to the healthcare provider must be offered what? Ans A printed copy of the provider privacy noticeWhich of the following statements apples to self insured insurance plans? Ans The employer provides a traditional HMO health planIn addition to the member's identification number, what information is recorded in a 270 transactionAns NameWhat process does a patient's health plan use to retroactively collect payments from liability automobile or worker's compensation plan?Ans In what type of payment methodology is a lump sum of bundled payment negotiated between the payer and some or all providers? Ans What Restriction does a managed care plan place on locations that must be used if the plan is to pay for the service provided? AnsSite of service limitationWhich of the following statements applies to private rooms? Ans If the medical necessity for a private room is documented in the chart. The patients insurance will be billed for the differentialWhich of the following is true about screening a beneficiary of possible MSP(Medicare secondary payer) situations? Ans It is necessary to ask the patient each of the MSP questionsWhich of the following is not true of Medicare Advantage Plans? Ans A patient must have both Medicare Part A and B benefits to be eligible for a Medicare Advantage planWhich of the following is a valid reason for a payer to deny a claim?Ans Failure to complete authorizationWhich of the following statements is NOT a possible consequence of selecting the wrong patient in the MPI(master patient index)AnsClaim is paid in fullWhich of the following statements is true of a Medicare Advantage Plan? Ans This plan supplements Part A and Part B benefitsWhich is the following is not a characteristic of Medicaid HMO plan? Ans Medicaid-eligible patients are never required to join a Medicaid HMO planWhich of the following is violation of the EMTALA ?AnsRegistration staff members routinely contact managed care plans for prior authorizations before the patients is seen by the on duty physicianWhich of the following statements is true of the important message from Medicare notification requirements? Ans Notification can be issued no earlier than 7 days before admission and no more than 2 days before discharge.What is the self pay balance after insurance Ans The portion of the adjudicated claim that is due from the patientWhich of the following options is an alternative to valid long term payment plans Ans BankloansThe patient has the following benefit plan $400 per family member deductible, to a maximum of $1200 per year and $2000 per family member co insurance, to a family maximum of $6000 per year excluding the deductible . Five family members are enrolled in this benefit plan. What is the maximum out of pocket expense that that family could incur during the calendar year?Ans$6000What type of plan restricts benefits for non-emergency care to approve providers only? Ans A POS (point of service )planWhat does scheduling allow provider staff to do? Ans Review the appropriateness of the service requestedWhen an adult patient is covered by both his own and his spouse health insurance plan, which of the statements is true? AnsThe patients insurance plan is primaryMrs. Jones , a Medicare beneficiary was admitted to the hospital on June 20,2010. As of the admission date, she had only used 8 inpatient days in the current benefit period. If she is not discharge on what date will Mr jones exhaust her full coverage days. AnsAugust 9, 2010In order to meet eligibility guidelines for healthcare benefits, Medicaid beneficiaries must fall into a specified need category and meet what other types of requirements AnsIncome and assetsFee for service plans pay claims based on a percentage of charges. How are patients out of pocket cost calculated? AnsThey are calculated quarterlyIndemnity plans usually reimburse what? Ans A certain percentage of charges after patient meets policy's annual deductible.Departments that need to be included in Charge master maintenance include all EXCEPTAns Quality AssuranceUsing HIPPA standardized transaction sets allow providers to: Ans Submit a standardized transaction to any of the health plans with which it conducts business.Which of the following is NOT included in the standardized quality measures? Ans Cost of servicesThe ACO investment model will test the use of pre-paid shared savings to: Ans Encourage new ACOs to form in rural and underserved areas.Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons on a monthly fee is known as: Ans HMOAmbulance services are billed directly to the health plan for:Ans Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility.Any provider that has filed a timely cost report may appeal in an adverse final decision received from the Medicare Administrative Contractor (MAC), the appeal may be filed with:AnsThe Provider Reimbursement Review Board.For scheduled payments, important revenue cycle activities in the time-of-service stage DO Not include:Ans Obtaining or updating patient and guarantor informationHospital can only convert an inpatient case to observation if:AnsThe hospital utilization review committee determines before the patient is discharged and prior to billing that an observation setting would be more appropriate.Hospital need which of the following information sets to assess a patient's financial status?Ans Demographic, Income, Assets and Expenses.HIPAA privacy rules require covered entities to take all, of the following actions EXCEPT: Ans Use only designated software platforms to secure patient date.When Recovery Audit Contractors (RAC) identify improper payments as overpayment. the claims processing contractor must: Ans Send a demand letter to the provider to recover the over payment amount.Which HIPPA transaction set provides electronic processing of 8insurance verification requests and responses? AnsThe 270-271 setAcross all care settings, if a patient consents to a financial discussion during a medical encounter to expedite discharge, the HFMA best practice is to:AnsSupport that choice, providing that the discussion does not interfere with patient care or disrupt patient flow.A scheduled inpatient represents an opportunity for the provider to do which of the following? Ans Complete registration and insurance approval before serviceThe Medicare Bundled Payments for Care Initiative (BCP) is designed to:AnsAlign incentives between hospitals, physicians, and non-physician providers in-order to better coordinate patient care.To maximize the value derived from customer complaints, all consumer complaints should be:Ans Tracked and shared to improve customer experienceThe soft cost of a dissatisfied customer is: Ans The customer passing on information about their negative experience to potential patients or through social media channels.Applying the contracted payment methodology to the total charges yields: Ans An estimate priceThe importance of medical records maintained by HIM is that the patient records: Ans Are the primary source for clinical data required for reimbursement by health plans and liability payersImportant Revenue Cycle Activities in the pre-service stage include: Ans Obtaining or updating patient and guarantor informationIn the pre-service stage, the cost of the schedule services is identified and the patient's health plan and benefits are used to calculate: Ans The amount the patient may be expected to pay after insurance.The disadvantage of outsourcing includes all, of the following Except Ans Reduces internal staffing costs and a reliance on outsourced staff.Marinating routine contact with health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of who: Ans Case ManagementA claim is denied for the following reasons EXCEPT: Ans The submitted claim does not have the physician signatureAll Hospitals are required to establish a written financial assistance policy that applies to: Ans All emergency and medically necessary careExamples of ethics violation that impact the revenue cycle include all of the following EXCEPT:Ans Seeking payment options for self-payVerbal orders from a physician for a service(s) are: Ans Acceptable if given to "qualified" staff as defined in a hospitals policies and proceduresMedicare has established guidelines called Local Coverage Determination (LCD) and National Coverage Determination (NCD) that establish:AnsWhat serviced or healthcare items are covered under Medicare?A decision on whether a patient should be admitted as an inpatient or become an outpatient observation patient requires medical judgement based on all of the following EXCEPT: Ans The patient's home care coverageWhat is the first step of the daily cash reconciliation process? Ans Obtaining cash, check, credit card and debit card payment from that dayThe healthcare industry is vulnerable to compliance issues, in large part due to the complexity of the statutes and regulations pertaining to:AnsMedicare and Medicaid paymentsThe correct coding initiative program consist of: Ans Edits that are implemented within provider's claim processing systemThe Affordable Health Care Act legislated the development of Health Insurance Exchange, where individuals and small businesses can: Ans Purchase health benefits plans regardless of insured's health statusBefore classifying and subsequently writing off an account to financial assistance or bad debit, the hospital must establish policy define appropriate criteria, implement procedures for identifying accounts and:AnsMonitor complianceThe Electronic Remittance Advice (ERA) data sets are: Ans A standardized for that provides 3rd party payment details to providersThe first and most critical step in registering a patient, whether scheduled or unscheduled is:Ans Verifying the patient's identificationThe standard claim form used for the billing by hospitals, nursing facilities, and other inpatient services is called the: AnsUB-04A four-digit number code established by the National Uniform Billing Committee (NUBC) that categorizes/classifies a line in the charge master is known as: Ans Revenue codesInternal controls addressing coding and reimbursement charges are put in place to guard against:Ans Compliance fraud by "upcoding"The 501(R) regulations require non-for-profit providers (501) ©(3) organizations to do which of the following activities: Ans Complete a community needs assessment and develop a discount program for patient's balances after insurance paymentDuring pre-registration, a search for the patient's MRI number is initiated using which of the following data sets: Ans Patient's full legal name and date of birth or the patient's Social Security numberTo maximize the value derived from customer complaints, all consumer complaints should be:Ans Tracked and shared to improve the customer experienceThe Business ethics, or organizational ethics represent: Ans The principles and standards by which organizations operateProviders are advised that it is best to establish patient financial responsibility and assistance policies and make sure they are followed internally and by: AnsThird-party payersThe advantage to using a third-part, collection agency includes all of the following EXCEPT:Ans Providers pay pennies on each dollar collected.Local Coverage Determination (LCD) and National Coverage Determinations (NCD) are Medicare established guidelines used to determine:AnsWhich diagnosis, signs, or symptoms are reimbursableClaims with the dates of service received later than one calendar year beyond the date of service will be:Ans Denied by Medicarein the pre-service stage, the requested service is screened for medical necessity, health plan coverage and benefits are verified and:AnsPre-authorization are obtainedFor scheduled patients, important revenue cycle activities in the time-of -service stage DO NOT include:Ans Final bill is presented for paymentIf a medical service authorization, who is typically responsible for obtaining the authorization:Ans The provider schedulingConcurrent review and discharge planning Ans Occurs during serviceThe fundamental approach in managing denials is: Ans To analyze the type and sources of denials and consider process changes to eliminate further denialsThe first thing a health plan does when processing a claim is: Ans Check if the patient is a health plan beneficiary and what is the coverageOutsourcing options should be evaluated as Ans Any other business service purchaseInsurance verification results in which of the following: Ans The accurate identification of the patient's eligibility and benefitsEMTLA and HFMA best practices specify that in an Emergency Department setting: Ans No patient financial discussions should occur before a patient is screened and stabilizedhe HCCAHPS (Hospital Consumer Assessment of Healthcare Provider's and Systems) initiative was launched to: Ans Provide a standardized method for evaluation patients' perspective on hospital careAll of the following are potential causes of credit balances EXCEPT: Ans A patient's choice to build up a credit against future medical billsMedicare will only pay for tests and services that: Ans Can be demonstrated asnecessaryThis was developed to promote and ensure healthcare quality and value and also to protect consumers and workers in the healthcare system. This directive is called: Ans Joint Commission for Acceleration of Healthcare Organizations (JCAHO) safety standardsIt is important to calculate reserves to ensure: Ans A stable financial operations and accurate financial reportingAn advantage of a pre-registration program in Ans The opportunity to reduce processing times at the time of serviceTo be eligible for Medicaid, an individual must: Ans Meet income and asset requirementsThe patient discharge process begins when: Ans The physician writes the orderAppropriate training for patient financial counseling staff must cover all of the following EXCEPT:Ans Documenting the conversation in the medical recordsPatients should be informed that costs presented in a price estimation may:Ans Only determine the percentage of the total that the patients is responsible for and not the actual cost.Any healthcare insurance plan that providers or insures comprehensive health maintenance and services for an enrolled group of persons based on a monthly fee is known as a Ans HMOChapter 11 Bankruptcy permits a debtor to: Ans Work out a court-supervised plan with creditorsA portion of the accounts receivable inventory which has NOT qualified for billing includes:Ans Accounts created during pre-registration but not activatedOverall aggregate payments made to a hospice are subject to a computed "cap amount" calculatedby:Ans The Medicare Administrative Contractor (MAC) at the end of the hospice cap periodThe ICD-10 code set and CPT/HCPCS code sets combined provide: Ans The specificity and coding accuracy needed to support reimbursement claimsCharges, as the most appropriate measurement of utilization, enables: Ans Generation of timely and accurate billingDays in A/R calculated based on the value of: Ans The total account receivable on a specific dateMedicare benefits provide coverage for: Ans Inpatient hospital services, skilled nursing care. And home health careHFMA best practices call for patient financial discussions to be reinforced: Ans By issuing a new invoice to the patientAll of following are steps in safeguarding collections EXCEPT: Ans Placing collections in a lock-box for posting review the next business dayThe code indication of the disposition of the patient at the conclusion of service is called the:Ans Patient discharge status codeHIPPA has adopted Employer Identification Numbers (EINs) to be used in standard transactions to identify the employer of an individual described in a transaction. EINs are created and assigned by:Ans The Internal RevenueServiceThe purpose of the ACA mandated Community Health Needs Assessment is:AnsTo provide community benefit outreach to those without insurance and who have not had a physical within the past 2 yearsWhat is Continuum of Care: Ans The coordination and linkage of resource needed to avoid the duplication of services and the facilitation of seamless movement among care settings.Account Receivable (A/R) aging reports Ans Identify past due accounts likely to become bad debitApplying the contracted payment amount to the amount of total charges yields: Ans An estimated price for the patient's responsibilityMost major health plans including Medicare and Medicaid offer: Ans Electronic and/or web portal verificationWhat are some elements of a board-approved financial assistance policy: Ans Eligibility application process and nonpayment collection activitiesWhich of the following is usually covered on a Conditions of Admissions form: Ans Patient's bill of rights.Net Accounts Receivable is Ans The amount an entity is reasonably confident of collection form overall accountsA common billing issue with hospital-based physician's is Ans They are not contracted with the patient's health plan to provide servicesWhat are collection agency fees based on ? Ans A percentage of dollars collectedSelf-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule?Ans BirthdayWhat customer service improvements might improve the patient accounts department?Ans Holding Staff accountable for customer service during performance reviewsWhat is an ABN(Advance Beneficiary Notice of Non-coverage) required to do? Ans Inform Medicare beneficiary that Medicare may not pay for the order or serviceWhat is the initial hospice benefit? Ans Two 90-day periods and an unlimited number of subsequent periodsHow should a provider resolve a late-charge credit posted after an account is billed? Ans Post a late- charge adjustment to the accountan increase in the dollars aged greater than 90 days from date of service indicate what aboutaccountsAns They are not being processed in a timely mannerWhat are the two statutory exclusions from hospice coverage? Ans Medically Unnecessary services and custodial careWhat statement applies to the scheduled outpatient? Ans The services do not include an overnight stayHow is a mis-posted contractual allowance resolved? Ans Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amountWhat type of patient status is used to evaluate the patients need for inpatient care?Ans ObservationCoverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what?AnsMedically necessary inpatient hospital services for at least 3 consecutive days before the skilled nursing care admission.When is the word "SAME" entered on the CMS 1500 billing form in feild 0 Ans When the patient is insuredIf the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? AnsNeither enrolled not entitled to benefitsRegulation Z of the consumer Credit Protection Act, also known as the Truth in lending Act establishes what? AnsDisclosure rules for consumer credit sales and consumer loansWhat is a principle diagnosis? Ans Primary reason for the patients admissionCollecting patient liability dollars after service leads to what? Ans Lower accounts receivable levelsWhat is the daily out-of-pocket amount for each lifetime reserve day used? Ans 50% of the current deductible amountWhat service provided to a Medicare beneficiary in a rural health clinic(RHC) is not billable as an RHC service? AnsInpatient careWhat code indicates the disposition of the patient at the conclusion of service? Ans Patient discharge status codeWhat are hospitals required to do for Medicare credit balance accounts? Ans They result in lost reimbursement and additional cost to collect.When an undue delay of payment results from a dispute between the patient and the third party payer, who is responsible for payment? AnsPatientWith advances in internet security and encryption, revenue-cycle processes are expanding to allow patients to do what? Ans Access their information and perform functions on-lineWhat date is required on all CMS 1500 claim forms? Ans onset date of currentillnessWhat code is used to report the provider's most common semiprivate room rate? Ans Condition codeRegulations and requirements for coding accountable care organizations which allows providers to begin creating these organizations were finalized in Ans2012What is a primary responsibility of the recover audit contractor? Ans To correctly identify proper payments for Medicare part A and B claimsHow must providers handle credit balances? Ans Comply with state statutes concerning reporting credit balanceWhat activities are completed when a scheduled pre-registered patient arrives for service? Ans Registering the patient and directing the patient to the service areaIn addition to being supported by information found in the patients chart, a CMS 1500 claim must be coded using what? AnsHCPCSWhat results from a denied claim? Ans The provider incurs rework and appeal costs