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Exam 10: Revenue Cycle Management

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Question 1

Multiple Choice

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CMS requires that hospitals have the requirement to issue _____________________ to Medicare patients either prior to admission, during the admission, or at any point if the care that the patient is receiving is not covered due to medical necessity, not delivered in the most appropriate setting, or if it is custodial.

A) Advance Beneficiary Notices
B) Certificates of Medical Necessity
C) Hospital-Issued Notices of Noncoverage
D) All of these are correct.
E) Only Certificates of Medical Necessity and Hospital-Issued Notices of Noncoverage

Correct Answer

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Question 2

Multiple Choice

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_____________________ is the first point of contact with the patient.

A) Patient scheduling
B) Insurance verification
C) Prior authorization
D) Financial counseling

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A

Question 3

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Utilization management is sometimes called utilization review (UR) where staff is responsible "for the day-to-day provisions of the hospital's utilization plan as required by the Medicare Conditions of Participation."

In a retrospective environment, both the provider and payer worked after the fact, in that the provider would bill for all services rendered but not really know if all the work was covered; they would find this out when the payment came into the facility.

Claims processing involves the totaling of charges for all services that a patient has incurred during their encounter. Once a patient has been discharged, the goal of the facility is to get a complete and accurate claim generated and submitted for payment to the payer.

_________________________________ are "the collection of the portion of the bill that is likely the responsibility of the patient before the provision of services."

Only in an emergency, the financial counselors should discuss and document the patient's responsibility for payment of any co-payment or deductible at the time of service and how they plan on paying the amounts that they are personally responsible for.

The middle process "represents the intersection of ________________ and billing".

In a prospective environment it is entirely up to the healthcare facility to manage their profit or loss with regard to a particular patient's hospital stay.

The maintenance of the CDM is a single disciplinary activity and requires one person or department to have oversight.

In the past, in the fee-for-service approach to managing the financial side of healthcare reimbursement, it was:

There are various tools that can support the front-end part of the revenue cycle that help capture data that aid in the securing of payment from the payers. These tools include all of the following, except:

________________________ contains all necessary information that will identify the item used, the charge associated with it, and the code that is associated with it that will enable the system to place the information on the claim form that will be sent to the payer.

________________________ is the next step in the registration process; it is a critical element and can sometimes be electronic.

_______________________ is "the evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilitates these under the provisions of the applicable health benefits plan."

___________________ is/are "a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for option and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes."

Payment posting is where the insurance company pays the claim that was submitted, and then once the facility receives payment, they can post the payment to the open accounts receivable. This posting:

The ________________________ in the revenue cycle is where case management is involved, charge capture, and hard coding and soft coding of diagnoses and procedures that are all based on clinical documentation.

The ______________________ entails payer negotiation that happens outside the patient encounter, the patient access component that includes the scheduling of the patient for inpatient or outpatient services, registration, insurance verification, obtaining prior authorization or a precertification if necessary, and patient financial counseling.

The Correct Coding Initiative (CCI), along with the Local Medical Review Policy (LMRP) and National Coverage Determination (NCD), edits need to be applied at the time of the original transaction taking place in the billing system and CDM.