CSPPM Study Guide (Certified Specialist Physician Practice Management)

Encounter report

* Patient & Provider demographic *Detailed charges and services *Clinical information specific to the encounter

Fee-for-service

Authorization and referrals

Used to have an immediate electronic receipt and provide edit and audit reports?

EDI

EDI

Electronic Date Interchange

GPCI

Geographic Practice Cost Index

RVU

Relative Value Unit

Insurance receivables fall into the following three specific categories, EXCEPT ________.

Rent receivables

RFP

Request for Proposal

RFI

Request for information

Types of Date:

Treatment of data and Gathering of data

Time frame for Encounter reports to be submitted?

within 72 hours

All of the following should be evaluated in a capital project, EXCEPT ___________.

Supply costs

Which option is NOT true regarding patient surveys?

Surveys can only be developed by an outside organization that specializes in conducting surveys

EHR

The implementation of the computer-based patient record is referred to as

What is not a key component of E/M services?

Time

What will reduce the practice DAR?

Timely submitting encounters

What is one purpose of financial counseling?

To minimize accounts receivable outstanding, particularly long-term payments

Purpose of financial counseling?

To minimize accounts receivables outstanding , particularly long-term payments

Purpose of Encounter

To provide info to the insurance plan about the treatment the patient received.

Customer Patient Surveys

Tools to measure effective customer and patient relations

In order to budget effectively each year, physicians may change all of the following, EXCEPT __________.

Units of service

Which option is NOT a requirement for the management of third-party receivables in a discounted fee-for-service contract?

Where patients are unable to pay the full amount, a payment plan may be necessary

Flexible Budget

a series of fixed budgets prepared under various assumptions about the possible levels of activity that may actually be experienced.

Underlying health plan

these are typically a high deductible health plan (HDHP) that will cover bigger health expenses such as surgery or hospitalization

Encounter report

to advise the health plans that patients have been treated, list the types of treatment rendered, and track specific diagnoses and procedures as required for other reporting mechanisms.

Comprehensive Budget

to the total management plan of the medical group as a whole and for each of its subdivisions (business units) and major activities.

Chapter 7

Chapter Seven bankruptcy is used when the patient has too few assets and little or no income to satisfy the debts.

Where the patient has no assets, would not be transferred to a collection agency, as the patient has no assets.

Charity Account

Charge posting

Collection of funds. It should occur as rapidly as possible, normally within 24 hours of service.

CDHP

Consumer Directed Health Plan

Which option is NOT a primary section included in an encounter report?

Contract terms and payment rates for the health plan.

ICD-10

Created in May 1990 by the 43rd World Health Assembly

CPT

Current Procedural Terminology

All of the following are examples of capitated receivables goals, EXCEPT ________.

Depositing the capitation check within 30 days of receipt

EHR

Electronic health record

Fee-for-Service

Encounter paid at a contracted rate and applied to charge

Under the RBRVS system, which of the following is NOT a component of resource consumption?

Geographic adjustments

All of the following are examples of applications of internal and external physician benchmarking, EXCEPT ______.

Patient days

Encounter

Patient treatment during a defined period. A single-date occurrence at a single provider

Who is responsible for accurate and correct use of CPT codes?

Physicians

All of the following components work together to manage risk in healthcare organizations, EXCEPT ________.

Point of Service Collections

Based on the principle that payments for physicians services should vary with the resource cost for providing those services and is intended to improve and stabilize the payment system while providing physician an avenue to improve it

RBRVS

Presents vendors with data about the medical group's operations, plus specific data about the operations being considered for a computer acquisition or enhancement.

RFI

A detailed document designed to help in the selection of an information services vendor or product, and it may or may not precede an RFI.

RFP

All of the following are impacts of the E/M coding changes, EXCEPT __________.

Reduced ability to code based on Total time

RBRVS

Resource Based Relative Value System

RVUs can be used in physician practice administration in all of the following ways, EXCEPT __________.

Reviewing physician practice quality

Bad Debts

results when a patient who has been determined to have the financial capacity to pay for healthcare services is unwilling to settle the claim (for example, a patient who has a bank account or other assets but chooses not to pay a legitimate bill).

Chapter 13

the patient uses existing assets and current and future income to pay the debts

Disadvantage of Internal Surveys

*Relaying on physician and staff to come up with questions *Skills sets to validate and develop questions *Patients will not answer questions if the staff is reviewing the questions

Criteria for Choosing a Collection Agency:

*Reputation *Patient relations *Agency fees *Retention and payment of agency fees *Report

Framework for Budgeting

*Setting Priorities *Allocating Resources *Monitoring Costs *Controlling Costs

CPT 5 sections

*Surgery *Anesthesia *Pathology *Radiology *E/M services

DAR

Days Accounts Receivable

HDHP

High Deductible Health Plan

Outsourcing Advantages

*A vendor may have access to staffing and/or computer systems not available to the medical group. *The vendor assumes responsibility for hiring, training, and supervision of staff. *The vendor may accept a contract that includes some financial risk if the cost of handling A/R increases or that includes an "efficiency" factor. *A vendor may receive economies of scale, not available to smaller medical groups, by handling A/R in a central location for a variety of groups *If A/R billing and collections are outsourced, it is critical to manage the vendor closely and hold them accountable for pre-determined and agreed-to deliverables.

Advantage of Internal Surveys

*Address directly the issues of importance to the practice *Less expensive than an external survey *Can monitor trends over time

Disadvantage of External Surveys

*Cash out of pocket cost

Revenue Cycle Functions

*Contracting and fee schedule analysis *Credentialing *Scheduling and registration *Encounter description *Charge posting *Claim processing *Accounts receivable and collection *Special billing issues

Outsourcing Disadvantages

*Decrease in direct control of accounts receivable *Potential negative impact on patient relations *Increased cost if the vendor is unable to provide the service less expensively than an in-house A/R *Legal considerations if the vendor staff represent themselves as employees of the medical group

Management of Third-party Receivables

*Encounter documented with retail charges *Produce a claim or electronic format *All required documentation is attached

Three sources of capital:

*Equity from Earnings *Equity from Donations *Long-term Debt

Applications for internal and external benchmarking:

*Expense per RVU *Gross charge per RVU *Net revenue per RVU *RVUs per physician *RVU productivity by specialty *RVUs per medical support staff FTE *RVUs per visit *Ratio of compensation per RVU

Insurance receivables fall into the following three specific categories:

*Fee-for-service Collection *Capitation Payment Collection *Collection of Balances Arising from Patient Co-pays, Co-insurance, and Deductibles

Components to manage risk

*Health Information Systems *Medical Records Documentation *Quality Assurance Programs *Case Management

Preparation of a rebill reasons:

*Initial bill not received *Patient rebilling *Rebills to secondary payers *Rebilling for litigation

Methods of Pre-Registration

*Online patient registration by patient or staff *Mailing of new patient form *Telephone call

5 Major groups of KPI's?

*Patient Access *Pre-Billing *Claims *Account Resolution *Financial Management

What diagnosis codes that can not be coded?

*Probable *Suspected *Questionable *Ruled out

Advantage of External Surveys

*Professional experience to develop and validate the survey *Provides benchmark performance from other practices

Accounts receivable

*Receivables due from third-party payers *Managed care capitation payments *Receivables due from patients

Continuum of care

*Referred specialty care *Outside diagnostic testing services *Rehabilitation services *Local Hospital Services

Steps used in the development of a medical group information system are as follows:

*System Analysis *System Design *System Acquisition *System Implementation

Components to a CDHP?

*Underlying health plan *Healthcare savings account

Three Components of Resource Consumption:

*Work related value (measure of skill, training, and knowledge) *Physical resource or cost *Cost associated with malpractice insurance

Who published the CPT?

AMA (American Medical Association)

AR

Accounts receivable

The E/M coding changes will have impact for all of the following, EXCEPT _____.

All specialties will receive a reduction in payment

AMA

American Medical Association

Performance Standards

Average days of revenue in receivables

Accounts will be written off to the bad debt account and, in most cases, should be transferred to a collection agency for follow-up against the patient's assets.

Bad debt

Two major deductions from accounts receivables?

Bad debt and Charity Account

Which option is NOT a technique used to measure accounts receivables?

Benchmarks

Key performance indicators (KPIs) for effective claims managment

DAR

Contains about 70,000 codes

ICD-10

ICD

International classification of diseases

Well defined metrics that illustrate performance?

KPI's

Healthcare savings account

allowing for the management of spending for smaller healthcare expenses such as office visits, routine care and prescriptions.

Overall budget (Comprehensive Budget)

composed of budget projections for statistics, revenues, expenses, capital expenditures, and cash flows

System Analysis

collecting information about current and needed systems organizing the information and providing documents to be used for the design stage

A ____________ budget is prepared under the single assumption about the anticipated activity level.

fixed

CMS 1500

form for the encounter processing

Financial counseling

is a patient and/or family-directed activity by the medical group with the goal of minimizing accounts receivable outstanding, particularly long-term payments.

Revenue budget

is a projection of income from all sources

Capital budget

is an annual process to estimate the resources committed for new projects, equipment, and facilities

Chapter 12

is available only to family farmers.

Salary Budget

is based upon the skill(jobs) needed to operate the practice

Charity Accounts

is defined as a legitimate debt that the patient does not have the ability to pay, and reimbursement for services is not expected (for example, a patient who has no insurance and incurs a bill far in excess of any assets or income).

Chapter 11

is generally restricted to those who operate a business.

Budgeting

is the overall process of formulating and monitoring future plans in numeric terms