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HFMA CRCR EXAM 2024 VERSION 600 EXAM
QUESTIONS WITH DETAILED VERIFIED ANSWERS
(100% CORRECT) AND RATIONALES /A+ GRADE
ASSURED
It is important to have high registration quality standards because a) Inaccurate or incomplete pt data will delay payment or cause denials b) Incomplete registrations will trigger exclusion from Medicare participation c) Inaccurate registration may cause discharge before full treatment is obtained d) Incomplete registrations will raise satisfaction scores for the hospital - ....ANSWER...A When recovery audit contractors (RAC) identify improper payments as over payments the claims processing contractor must a) Assume legal responsibility for repaying the overage amount b) Make recovery of the overpayment the top processing priority c) Send a demand letter to the provider to recover the over payment amount d) Conduct an audit of all the effected providers claims within the past 12 months - ....ANSWER...C Internal controls addressing coding and reimbursement changes are put I place to guard against a) Underpayments b) Denials c) Compliance fraud by upcoding d) Charge master error - ....ANSWER...C The pt discharge process begins when a) The physician writes the discharge orders
b) Clinical services are completed and pt accounts have all the info necessary to bill c) The physician writes the discharge orders and the third-party payer sign-off on the necessity of the services provided d) Clinical services are completed, pt accounts can generated and accurate bill and there is agreement o the handling of pt financial responsibilities - ....ANSWER...A Most major health plans including medicare and Medicaid, offer a) Toll free verification hot lines, staffed around the clock b) Electronic and/or web portal verification c) Pt "verification of benefits" cards d) A grace period for obtaining verification within 72 hours of treatment - ....ANSWER...B The physician who wrote the order for an inpatient service and is in charge of the pts treatment during admission is a) The pts personal physician b) The primary care physician c) The attending physician d) The physician pt care director - ....ANSWER...C An originating site is a) The location where the pts bill is generated b) The location of the pt at the time the service is provided c) The site that generates reimbursement of a claim d) The location of the medical treatment provider - ....ANSWER...B HFMA best practices stipulate that a reasonable attempt should be made to have the financial responsibilities discussion a) As early as possible, before a financial obligation is incurred b) During the registration process
registration forms and instructions b) Make sure that the attending staff can answer questions and assist in obtaining required pt financial data c) Support that choice, providing that the discussion does not interfere with pt care or disrupt pt flow d) Decline such request as finance discussions can disrupt pt care and pt flow - ....ANSWER...C The office of inspector general (OIG) publishes a compliance work plan a) Monthly b) Quarterly c) Semi-annually d) Annually - ....ANSWER...D What are collection agency fees based on? - ....ANSWER...A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - ....ANSWER...Birthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - ....ANSWER...Case rates What customer service improvements might improve the patient accounts department? - ....ANSWER...Holding staff accountable for customer service during performance reviews What is an ABN (Advance Beneficiary Notice of Non-coverage) required to do? - ....ANSWER...Inform a Medicare beneficiary that Medicare may not pay for the order or service
What type of account adjustment results from the patient's unwillingness to pay for a self-pay balance? - ....ANSWER...Bad debt adjustment What is the initial hospice benefit? - ....ANSWER...Two 90 - day periods and an unlimited number of subsequent periods When does a hospital add ambulance charges to the Medicare inpatient claim? - ....ANSWER...If the patient requires ambulance transportation to a skilled nursing facility How should a provider resolve a late-charge credit posted after an account is billed? - ....ANSWER...Post a late-charge adjustment to the account an increase in the dollars aged greater than 90 days from date of service indicate what about accounts - ....ANSWER...They are not being processed in a timely manner What is an advantage of a preregistration program? - ....ANSWER...It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - ....ANSWER...Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - ....ANSWER...Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts What statement applies to the scheduled outpatient? - ....ANSWER...The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - ....ANSWER...Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount
an increase in the dollars aged greater than 90 days from date of service indicate what about accounts - ....ANSWER...They are not being processed in a timely manner What is an advantage of a preregistration program? - ....ANSWER...It reduces processing times at the time of service What are the two statutory exclusions from hospice coverage? - ....ANSWER...Medically unnecessary services and custodial care What core financial activities are resolved within patient access? - ....ANSWER...Scheduling, insurance verification, discharge processing, and payment of point-of-service receipts What statement applies to the scheduled outpatient? - ....ANSWER...The services do not involve an overnight stay How is a mis-posted contractual allowance resolved? - ....ANSWER...Comparing the contract reimbursement rates with the contract on the admittance advice to identify the correct amount What type of patient status is used to evaluate the patient's need for inpatient care? - ....ANSWER...Observation Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? - ....ANSWER...Medically 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 Field 0$? - ....ANSWER...When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - ....ANSWER...Unscheduled patients
If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - ....ANSWER...Neither enrolled not entitled to benefits Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what? - ....ANSWER...Disclosure rules for consumer credit sales and consumer loans What is a principal diagnosis? - ....ANSWER...Primary reason for the patient's admission Collecting patient liability dollars after service leads to what? - ....ANSWER...Lower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - ....ANSWER...50% of the current deductible amount What service provided to a Medicare beneficiary in a rural health clinic (RHC) is not billable as an RHC services? - ....ANSWER...Inpatient care What code indicates the disposition of the patient at the conclusion of service? - ....ANSWER...Patient discharge status code What are hospitals required to do for Medicare credit balance accounts? - ....ANSWER...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? - ....ANSWER...Patient Medicare guidelines require that when a test is ordered for a LCD or NCD exists, the information provided on the order must include: - ....ANSWER...A valid CPT or HCPCS code
....ANSWER...HCPCS (Healthcare Common Procedure Coding system) What results from a denied claim? - ....ANSWER...The provider incurs rework and appeal costs Why does the financial counselor need pricing for services? - ....ANSWER...To calculate the patient's financial responsibility What type of provider bills third-party payers using CMS 1500 form - ....ANSWER...Hospital-based mammography centers How are disputes with nongovernmental payers resolved? - ....ANSWER...Appeal conditions specified in the individual payer's contract The important message from Medicare provides beneficiaries with information concerning what? - ....ANSWER...Right to appeal a discharge decision if the patient disagrees with the services Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - ....ANSWER...To improve access to quality healthcare If a patient remains an inpatient of an SNF (skilled nursing facility for more than 30 days, what is the SNF permitted to do? - ....ANSWER...Submit interim bills to the Medicare program.
- MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - ....ANSWER... days passes, but the claim then be withdrawn from the liability carrier Coverage rules for Medicare beneficiaries receiving skilled nursing care require that the beneficiary has received what? -
....ANSWER...Medically 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 Field 0$? - ....ANSWER...When the patient is the insured What are non-emergency patients who come for service without prior notification to the provider called? - ....ANSWER...Unscheduled patients If the insurance verification response reports that a subscriber has a single policy, what is the status of the subscriber's spouse? - ....ANSWER...Neither enrolled not entitled to benefits Regulation Z of the Consumer Credit Protection Act, also known as the Truth in Lending Act, establishes what? - ....ANSWER...Disclosure rules for consumer credit sales and consumer loans What is a principal diagnosis? - ....ANSWER...Primary reason for the patient's admission Collecting patient liability dollars after service leads to what? - ....ANSWER...Lower accounts receivable levels What is the daily out-of-pocket amount for each lifetime reserve day used? - ....ANSWER...50% of the current deductible amount What service provided to a Medicare beneficiary in a rural health clinic (RHC) is not billable as an RHC services? - ....ANSWER...Inpatient care What code indicates the disposition of the patient at the conclusion of service? - ....ANSWER...Patient discharge status code
Insurance verification results in what? - ....ANSWER...The accurate identification of the patient's eligibility and benefits What form is used to bill Medicare for rural health clinics? - ....ANSWER...CMS 1500 What activities are completed when a scheduled pre-registered patient arrives for service? - ....ANSWER...Registering the patient and directing the patient to the service area In addition to being supported by information found in the patient's chart, a CMS 1500 claim must be coded using what? - ....ANSWER...HCPCS (Healthcare Common Procedure Coding system) What results from a denied claim? - ....ANSWER...The provider incurs rework and appeal costs Why does the financial counselor need pricing for services? - ....ANSWER...To calculate the patient's financial responsibility What type of provider bills third-party payers using CMS 1500 form - ....ANSWER...Hospital-based mammography centers How are disputes with nongovernmental payers resolved? - ....ANSWER...Appeal conditions specified in the individual payer's contract The important message from Medicare provides beneficiaries with information concerning what? - ....ANSWER...Right to appeal a discharge decision if the patient disagrees with the services Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - ....ANSWER...To improve access to quality healthcare
If a patient remains an inpatient of an SNF (skilled nursing facility for more than 30 days, what is the SNF permitted to do? - ....ANSWER...Submit interim bills to the Medicare program.
- MSP (Medicare Secondary Payer) rules allow providers to bill Medicare for liability claims after what happens? - ....ANSWER... days passes, but the claim then be withdrawn from the liability carrier What data are required to establish a new MPI entry? - ....ANSWER...The patient's full legal name, date of birth, and sex What should the provider do if both of the patient's insurance plans pay as primary? - ....ANSWER...Determine the correct payer and notify the incorrect payer of the processing error What do EMTALA regulations require on-call physicians to do? - ....ANSWER...Personally appear in the emergency department and attend to the patient within a reasonable time At the end of each shift, what must happen to cash, checks, and credit card transaction documents? - ....ANSWER...They must be balanced What will cause a CMS 1500 claim to be rejected? - ....ANSWER...The provider is billing with a future date of service Under Medicare regulations, which of the following is not included on a valid physician's order for services? - ....ANSWER...The cost of the test how are HCPCS codes and the appropriate modifiers used? - ....ANSWER...To report the level 1, 2, or 3 code that correctly describes the service provided If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? - ....ANSWER...Diagnostic and clinically-related non-diagnostic charges provided on the Tuesday, Wednesday, Thursday, and Friday before admission
How does utilization review staff use correct insurance information? - ....ANSWER...To obtain approval for inpatient days and coordinate services When is it not appropriate to use observation status? - ....ANSWER...As a substitute for an inpatient admission What is a serious consequence of misidentifying a patient in the MPI?
- ....ANSWER...The services will be documented in the wrong record When a patient reports directly to a clinical department for service, what will the clinical department staff do? - ....ANSWER...Redirect the patient to the patient access department for registration What process can be used to shorten claim turnaround time? - ....ANSWER...Send high-dollar hard-copy claims with required attachments by overnight mail or registered mail How are patient reminder calls used? - ....ANSWER...To make sure the patient follows the prep instructions and arrives at the scheduled time for service If a patient declares a straight bankruptcy, what must the provider do?
- ....ANSWER...Write off the account to the contractual adjustment account According to the Department of Health and Human Services guidelines, what is NOT considered income? - ....ANSWER...Sale of property, house, or car The situation where neither the patient nor spouse is employed is described to the patient using: - ....ANSWER...A condition code What option is an alternative to valid long-term payment plans? - ....ANSWER...Bank loans
What is an advantage of using a collection agency to collect delinquent patient accounts? - ....ANSWER...Collection agencies collect accounts faster than hospital does What statement DOES NOT apply to revenue codes? - ....ANSWER...revenue codes identify the payer When a patient's illness results in an unusually high amount of medical bills not covered by insurance or other patient pay resources, what type of account is created - ....ANSWER...catastrophic charity What happens when a patient receives non-emergent services from and out-of-network provider? - ....ANSWER...Patient payment responsibility is higher Every patient who is new to the healthcare provider must be offered what? - ....ANSWER...A printed copy of the provider's privacy notice How may a collection agency demonstrate its performance? - ....ANSWER...Calculate the rate of recovery What is true of the information the provider supplies to indicate that an authorization for service has been received from the patient's primary payer? - ....ANSWER...It is posted on the remittance advice by the payer What standard claim forms are currently used by the healthcare industry to submit claims to third-party payers? - ....ANSWER...The UB-04 and the CMS 1500 Unless the patient encounter is an emergency, what is the efficient and effective procedure for obtaining information? - ....ANSWER...Obtain the required demographic and insurance information before services are rendered
What statement describes the APC (Ambulatory payment classification) system? - ....ANSWER...APC rates are calculated on a national basis and are wage-adjusted by geographic region What is a benefit of insurance verification? - ....ANSWER...Pre- certification or pre-authorization requirements are confirmed What is an effective tool to help staff collect payments at the time of service? - ....ANSWER...Develop scripts for the process of requesting payments What is a benefit of electronic claims processing? - ....ANSWER...Providers can electronically view patient's eligibility What does Medicare Part D provide coverage for? - ....ANSWER...Prescription drugs What are some core elements of a board-approved financial policy - ....ANSWER...Charity care, payment methods, and installment payment guidelines What circumstance would result in an incorrect nightly room charge?
- ....ANSWER...If the patient's discharge, ordered for tomorrow, has not been charted What is NOT a typical charge master problem that can result in a denial? - ....ANSWER...Does not include required modifiers Access - ....ANSWER...An individual's ability to obtain medical services on a timely and financially acceptable level Administrative Services Only (ASO) - ....ANSWER...Usually contracted administrative services to a self-insured health plan Case management - ....ANSWER...The process whereby all health- related components of a case are managed by a designated health
professional. Intended to ensure continuity of healthcare accessibility and services Claim - ....ANSWER...A demand by an insured person for the benefits provided by the group contract Coordination of benefits (COB) - ....ANSWER...a typical insurance provision that determines the responsibility for primary payment when the patient is covered by more than one employer-sponsored health benefit program Discounted fee-for-service - ....ANSWER...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 - ....ANSWER...Patient status regarding coverage for healthcare insurance benefits First dollar coverage - ....ANSWER...A healthcare insurance policy that has no deductible and covers the first dollar of an insured's expenses Gatekeeping - ....ANSWER...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 - ....ANSWER...an insurance company that provides for the delivery or payment of healthcare services Indemnity insurance - ....ANSWER...negotiated healthcare coverage within a framework of fee schedules, limitations, and exclusions that is offered by insurance companies or benevolent associations Medically necessary - ....ANSWER...Healthcare services that are required to preserve or maintain a person's health status in accordance with medical practice standards
