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Reimbursement Test 4 study guide

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rad2329's version from 2016-11-29 18:18

Section 1

Question Answer
Revenue cycle definitionRevenue is regular income, and the cycle is the regularly repeating set of events that produces it
Revenue cycle management (RCM) definitionAll administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue
Soft Coding definitionCoding by HIM (When codes are left off the charge master and entered later by HIM personnel. Also known as dynamic coding).
What is account receivable?Management of the amounts owed to a facility by customers who received services and plan to pay later (Handles claims going out and coming in)
What is a remittance advice and who is it provided to?Explains payments made by third-party payers (i.e.) Reports claim (Rejections, Denials, Partial payment, Full payment).
What is “Dollars in account receivable”?Ending accounts receivable balance for the period divided by the Average revenue per day
Charge description definition?An explanatory phrase that has been assigned to describe the procedure, service or supply rendered
What is a Revenue Code?A four digit numeric code that is required for billing on the UB04 or the 837I ETS.
Explanation of Benefits (EOB) Definition?Statement that describes services rendered, payment covered, and benefit limits and denials
What is reimbursement?Recovering the costs and resources used in delivering treatment services
What is Contractual allowance?The difference between what hospitals bill and what they receive in payment from third party payers, most commonly government programs; also known as contractual adjustment.
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Section 2

Question Answer
What is Remittance advice (RA)?Explains payments made by third-party payers (i.e.) Reports claim: Rejections, Denials, Partial payment, Full payment
What is Advance Beneficiary Notice (ABN)?also known as a waiver of liability, is a notice you should receive when a provider or supplier offers you a service or item they believe Medicare will not cover. ABNs only apply if you have Original Medicare, not if you are in a Medicare Advantage private health plan.
What is meant by “Silo mentality”?Each department is responsible for its functions, Promotes hostility among departments. An attitude that is found in some organizations; it occurs when several departments or groups within an organization do not want to share information or knowledge with other individuals in the same organization.
What are the Major functions of revenue cycle?Admitting, Case management, Charge capture, Coding, Patient financial services, Finance, Compliance. Information technology
What are the basic revenue cycle components?Pre-Claims submission, Claims Processing, Accounts Receivable, Claims Reconciliation and Collections.
What is the function and role of Medicare Administrative Contractors (MACs)?Process Part A and B claims for services by physicians, medical suppliers and hospitals: Determine the charges allowed by Medicare, Make payments to physicians and suppliers for Part-B covered services, Determine costs and reimbursement amounts, Conduct reviews and audits, Make payments to providers for covered services.
What is a Medicare Code Editor?A software program used to detect and report errors in coding while processing inpatient hospital claims.
What is involved (activities or departments) in pre-claims submission?Appointments/preregistration/registration: Registration clerk (admitting) collects patient demographic and insurance billing data, Patient education of payment policies
Who monitors the aging of accounts reports in the revenue cycle team?Accounts Receivable - 30-day increments (Look at in 30 day increments, i.e. 30 days, 60-90 days etc.)
What duties or activities can be found in the Claims reconciliation/collection area?Write-offs, Adjustments, Re-submit coding changes
The revenue code is set by ?The DHHS and is the same at all facilities.
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Section 3

Question Answer
The revenue code reported on individual claims is utilized at ?The end-of-year cost reporting process.
Revenue code assignment is usually driven by ?The ancillary department or location where the service was rendered.
What is in the Medicare Claims Processing Manual?Day-to-day operating instructions, policies and procedures based on statues, regulations, guidelines, models and directive are included in the manual. Go to this for compliance guidance.
CMS Program Transmittals?Used by Medicare to communicate policies and procedures for specific prospective payment systems
Types of errors that cause claim rejections or denials found by scrubbers?Incompatible dates of service, Nonspecific or inaccurate diagnosis and procedure codes, Lack of medical necessity, Inaccurate revenue code assignment, Failure to follow contract-specific requirements
What does the accounts receivable department handle?Claims going out and claims coming in.
The CPT/HCPCS code sets were established by ? The Health Information Portability and Accountability Act of 1996 (HIPAA)
True or false: Charge does not equal cost?True
True or false: Charge is not the last piece in the CDM structure?False
Charge is ?The hospital price for the item or service rendered to the patient
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Section 4

Question Answer
National coverage determinations (NCDs) Describe the circumstances under which specific medical supplies, services or procedures are covered nationwide by Medicare.
Why improve RCM (Revenue Cycle Management) ?Decrease payment delays and lost revenue (This is the most important reason to improve), Improve patient satisfaction,
** VBP and P4P systems link ? Quality Performance and Payment together.
VBP and P4P share characteristics in priority order: ?Measurement, Transparency, Accountability
VBP: Common use since ?Deficit Reduction Act (DRA) of 2005
ACA (Affordable Care Act) of 2010 encouraged ?Experimentation in VBP/P4P design
What is Patient-Centered Medical Home (PCMH)?model of primary care that seeks to meet the healthcare needs of patients and to improve and patient and staff experiences, outcomes, safety, and system efficiency (Coordinate the care of patients for a particular spectrum)
Accountable Care Organization (ACO) three essential characteristics?Ability to manage patients across the continuum of care, including acute, ambulatory, and post-acute health services, - Capability to prospectively plan budgets and resources needs - Sufficient size to support comprehensive, valid, and reliable measurement of performance
CMS Vision ?The right care for every person, every time
Documentation should ?Complete, legible, and timely.
Balance Budget Act (BBA): focused on ?fraud and abuse issues specifically in relation to penalties.
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Section 5

Question Answer
Compliance Plan Goal?Prevent accusations of fraud and abuse, Make operations run smoothly, Improve services, Contain costs
The basic elements of a coding plan should include:Code of Conduct, Policies and Procedures, Education and Training, Communication, Auditing, Corrective Action, Reporting
What is Corrective Action? Prevention of the same or similar problems in the future.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 directed the Department of Health and Human Services to conduct a three year demonstration program using Recovery audit contractors (RAC) to detect and correct improper payments in the Medicare Fee for Service program.
The RAC program provided CMS with another tool for ?detecting improper payments made in the past and has also given CMS a valuable mechanism for preventing future inappropriate payments.
The Tax Relief and Health Care Act of 2006 subsequently made the RAC program ?a permanent one and required the Secretary of DHHS to expand the program to all 50 states no later than January 1, 2010.
The RACs conduct two types of audits:Automated, Complex Reviews
**What is Unbundling?The practice of using multiple codes that describe individual components of a procedure rather than an appropriate single code that describes all of the steps of the procedure performed.
**What is Upcoding?The practice of assigning a diagnosis or procedure code specifically for the purpose of obtaining a higher level of payment.
What is a payer identifier?Codes that are used to differentiate among payers that may have specific or special billing protocol
What is a modifier?Used to flag a service that has been modified in some way or to provide more specific information about the procedure or service
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