Healthcare Finance
For pricing purposes, the ANSI X12N 837 P (837P) Electronic Claim Form, when the Place of Service (POS) is listed as __________, and the pricing will be based on where the beneficiary's home is located. -10 -11 -12 -24
-12
A request for redetermination must be filed within ____ days after receiving the notice of the initial determination. -90 -60 -120 -180
-120
According to CMS, the timing and content for certification are for the first 90 days of hospice coverage. The hospice must obtain, no earlier than _____ days prior to care and no later than _____ calendar days after hospice is initiated, oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice organization. -30, 10 -15, 2 -10, 10 -60, 15
-15, 2
OPPS has frozen the outpatient hospital coinsurance at _________ of the national median charge for the services within each APC, but the coinsurance amount for an APC cannot be less than this percentage of the APC payment rate. -10% -15% -20% -25%
-20%
Urban Clinic is establishing a new Women's Breast Center at an initial investment cost of $2,000,000. Monthly operating expenses are expected to be $100,000, and the center is expected to generate $40,000 in profits each month. What is the estimated return on investment of this project for one year? -5% -10% -24% -48%
-24%
Which of the following types of service are subject to the home health consolidated billing provision? -Skilled nursing care -Routine medical supplies -Speech-language pathology -All of these are correct -Both skilled nursing care and speech-language pathology
-All of these are correct -Skilled nursing care -Routine medical supplies -Speech-language pathology
An IRF PPS payment is calculated by the ______________________ code assigned to the patient—a five-character alphanumeric code that encompasses the information about the case-mix group and comorbidity. -HIPPS -HOPPS -HHRG -HH PPS
-HIPPS
Quality charge capture ensures that payment and reimbursement rates are established for all of the following except _____. -APCs -DRGs -ICD-10 -HCPCS
-ICD-10
The OIG understands that the physician practice should be able to order tests, including screening tests that they believe are appropriate for treating their patients. With that said, Medicare will only pay for services that meet the Medicare definition of reasonable and necessary. -True -False
-True
Typically, a split percentage payment is made to the home care agency. The payments consist of an initial payment and final payment; the initial payment is in response to a Request for Anticipated Payment (RAP) from the home care company. -True -False
-True
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." -True -False
-True
All of the following functions are ways that MCOs work toward their goal of controlling costs except _____. -Use of clinical practice guidelines -Negotiating discounted prices -Controlling patients' access to care -Using a primary care provider to coordinate care
-Use of clinical practice guidelines
The PPACA focused on improving quality and, at the same time, lowering costs. When the ______________________________ was established, it offered financial incentives to hospitals to improve the quality of care delivered to the patient. -ACO -VBP -DRG -P4P
-VBP
The __________ were created to perform program integrity functions in zones for Medicare Part A and Part B, Durable Medical Equipment (DME), Prosthetics, Orthotics, Supplies, Home Health and Hospice, and Medicare-Medicaid data matching. -RACs -ZPICs -Medicare Fraud and Abuse Laws -None of these are correct.
-ZPICs
The ability for the coder to effectively code a patient's medical record requires ______________________________________. -a complete medical record. -legible documentation. -consistent documentation. -consistent, complete and legible documentation.
-consistent, complete and legible documentation.
Payment rates for APCs, outside of drugs and biologicals, are products of the relative weight of the APC and the OPPS: _________ -wage index. -COLA. -base rate. -conversion factor.
-conversion factor.
The ability of an organization to measure _________ throughout the manufacturing and sales cycle is done through the appropriate classification of this data which will provide a variety of additional data for the management team. -revenue -profits -costs -both revenue and costs
-costs
The OASIS data are collected at all of the following times, except: ________________________ -significant changes in condition -death in the hospital -discharge from the HHA -resumption of care after inpatient hospitalization.
-discharge from the HHA
_______________ ultimately supports the recognition principles in that assumptions are explained that are part of the numeric information; these provide additional information to the person reading the financial reports. -Auditing -A financial statement -Disclosure -GAAP
-disclosure
According to GAAP, there are two categories of accounting principles: recognition and _________________. -disclosure -preparation -auditing -budgeting
-disclousre
In HCC coding, all diagnoses are _____________________ to reflect the current status of the patient's chronic conditions. -drilled down -not uncomplicated -at the appropriate level -drilled down and at the appropriate level -drilled down, not uncomplicated, and at the appropriate level
-drilled down and at the appropriate level
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. -back-end process -middle process -front-end process -silo approach -None of these are correct.
-middle process
If ____________ ambulance(s) transported the patient from the initial pick-up location to the final destination, the jurisdiction is with the carrier that is at the point of origin of the ambulance. -three -two -one -None of these are correct.
-one
When two or more people get together to form an organization, it is called a: ________________________ sole proprietorship. -partnership. -corporation. -not-for-profit. -for-profit.
-partnership
The components of _________________________________ are focused in three areas, which are a past history of a patient's illness and any treatment or surgical procedures that were done in the past. -past family and/or social history -chief complaint -review of systems -medical decision-making -history of present illness
-past family and/or social history
The purpose of HCC coding is to reflect the health of a ________________ accurately. -patient population -patient population with like resource consumption -Medicare beneficiary pool -select subgroup of a chronic population
-patient population
Increasing the RCM performance will have a ______________ impact on the overall health of the organization's financial condition. -neutral -negative -positive -varying
-positive
The Federal Accounting Standards Advisory Board mission is that it serves the _______________ interest by improving federal financial reporting through issuing federal financial accounting standards. -private -federal government -public -business
-public
All documentation is essential for ____________________ of the claims as the payers want to see documentation that is consistent, accurate, complete, and timely to cover the services that are being billed for by the provider. -accuracy -completeness -outcomes -reimbursement
-reimbursement
Beginning accounts receivable plus _____________ less collections equals _____________. -accounts payable, ending accounts receivable -sales, ending accounts receivable -inventory, ending accounts payable -None of these are correct.
-sales, ending accounts receivable
The CMS Self-Referral Disclosure Protocol (SRDP) enables providers of services and suppliers to ______________ actual or potential violations of the physician self-referral statute. -report internally -self-disclose -fix the issue and not report the -None of these are correct.
-self-disclose
The _________________ of allocating costs will distribute the costs involved with overhead to the revenue-producing departments. These costs will be distributed to the individual revenue-generating departments based on a percentage of revenue or square footage. -direct method -step-down allocation method -simultaneous equations method -double distribution method
-step-down allocation method
The _____________________ is designed to distribute the indirect costs starting with the department that provides the least amount of revenue-generating services. -direct method -step-down allocation method -double distribution method -simultaneous equations method
-step-down allocation method
Charges to the beneficiary for admission or readmission are not allowable, however, there is an exception when a resident leaves a skilled nursing facility (SNF): ______________ -against medical advice. -temporarily. -upon discharge to home. -None of these are correct.
-temporarily.
During the stay, the patient must receive close medical attention and have at least ________ face-to-face visits per week by a licensed physician with specialized training in rehabilitative medicine. -two -three -four -five
-three
ICD-9-CM diagnosis codes vary in length anywhere from __________ digits. -two to three -three to four -three to five -four to six
-three to five
In 2010, the PPACA put insurance coverage online for consumers to compare coverage between plans and pick the best one for their needs. Most importantly, the rules were changed ______________ to children under the age of 19 due to a preexisting condition. -to discourage insurance companies from denying coverage -to stop insurance companies from denying coverage -to allow insurance companies to dny coverage -None of these are correct.
-to stop insurance companies from denying coverage
The False Claims Act (FCA) of the United States Code Sections 3729-3733 protects the government from being overcharged or sold substandard goods or services. -True -False
-treu
A Prior Authorization (PA) is also considered a cost control measure for the MCOs. -True -False
-true
By focusing on improving quality and lowering costs, the PPACA shifted the risk to the provider to deliver quality care and lower costs. This was done through the bundle payment, in that the provider was entirely responsible for their profit and loss on a patient but had to balance out quality care and access at the same time. -true -False
-true
In addition to reducing costs and improving access and quality care for the Medicare beneficiary, the PPACA will help to tighten up and reduce the overpayments to the insurance companies. -True -False
-true
Medicare abuse is when a supplier or practitioner either directly or indirectly has practices that result in unnecessary costs to the Medicare Program. -True -False
-true
NCQA is an accrediting entity as identified by the Department of Health and Human Services (HHS) for Qualified Health Plan. NCQA is a private, not-for-profit organization that focuses on accreditation, certification, and recognition of health plans and reports on the overall quality of managed care plans in the United States. -True -False
-true
Physician documentation is a key element to verify and support precisely what services were provided. -True -False
-true
Since the inception of the Comprehensive Error Rate Testing Program (CERT), CMS has reduced improper payments from 9.8% in 2003 to 3.9% in 2007. -True -False
-true
The PPACA was enacted on March 23, 2010, and shortly after, the name of the act was changed to the Health Care Reconciliation Act of 2010. -True -False
-true
In the PPACA, individuals have the right to choose the doctor that they want to care for them from the insurance companies' list of network providers. The individuals can also use an out-of-network emergency room provider: -without penalty. -with a higher copay. -as long as they get a referral. -if they were admitted to the hospital.
-without penalty.
The determination for payment in the long-term institutional program is based on the minimum 90-day assessment by the nursing home. The tool used for this measurement is the: ___________ Minimum Data Set. Diagnosis-Related Grouper. resource-Based Relative Value Scale. None of these are correct.
Minimum Data Set.
_________________________ is where accounting information is a tool to communicate without providing any influence that would sway a decision in a particular direction, or that would favor a particular interest group. -Relevance of information -Faithful representation -Neutrality -Usefulness for decision
Neutrality
Answer the question using the POA indicators: Y = Yes N = No U = Unknown W = Clinically undetermined Scenario 2: A patient is admitted for an appendectomy. Postoperatively, the patient develops a pulmonary embolism. What is the POA indicator for the pulmonary embolism? Y N U W
No
The typical pay-for-performance program will provide a bonus to healthcare providers for meeting or exceeding agreed upon: _______________ quality measures. performance goals expense management. both quality measures and performance goals. None of these are correct.
both quality measures and performance goals.
_____________________ measures how well the facilities, equipment, and personnel were used in the treatment of the patient. Process Outcome Patient experience Structure
Structure
Payment status indicator _________ is for surgical procedures where multiple procedure reductions apply. -S -T -V -X
T
According to CMS, certain combinations of ____________________ for an individual can increase the overall medical costs for a beneficiary more than what the CMS HCC model reflects. coexisting diagnoses multiple procedures admissions duplicate diagnoses
coexisting diagnoses
Multiple chronic diseases are considered part of the risk-adjusted payment model based on the assignment of diagnoses to disease groups, also known as: __________ condition categories. primary diagnoses. diagnosis-related groups. None of these are correct.
condition categories.
Hierarchies are comprised of condition categories, reflecting severity and: ___________ cost dominance. admission diagnoses. discharge disposition. case-mix index.
cost dominance.
The HCC model is used to calculate risk scores that predict: _________ outcomes. costs for an individual patient. costs for a pool of patients. case-mix index.
costs for a pool of patients.
_______________________ is similar to the PPO, except that the patients enrolled in the plan are to receive healthcare services only from the network providers. -HMO -PPO -POS -EPO -IDS
epo= exclusive provider organizations
By providing risk-adjusted payments, CMS can make more accurate and appropriate payments for beneficiaries with differences in: _______ admission diagnoses. expected costs. discharge disposition. expected revenues.
expected costs.
A penalty that Medicare has imposed on hospitals is when a patient acquires a pressure sore during the hospital admission, Medicare will continue to pay for the treatment of the pressure sore during the patient's hospital stay as they did in the past. True False
false
In coding the BMI, a coder can report the BMI without an accompanying weight-related diagnosis. -True -False
false
The Hospital Value-Based Purchasing (VPB) Program is a CMS initiative that rewards acute-care hospitals with incentive payments based on the cost of care that they provide to the beneficiary/patient who receives Medicare while they are in their care. True False
false
Unfortunately, Medicaid has historically had a lower reimbursement than other plans, and this has driven away providers from the plans. Even with fewer providers, Medicaid seems to get the results that other plans get with higher reimbursements. True False
false
When coding a record that consists of a chronic condition, such as CKD, the ICD-10-CM coding guidelines tell a coder that they can't assume a causal link between most systemic disorders that a patient may have and diabetes. -True -False
false
Which of the following statements about the IPPS high-cost outlier provision is false? -The outlier payment ensures hospitals will not experience a financial loss for the encounter -When the fixed-loss cost threshold is exceeded, an outlier payment is made for the encounter -The high-cost outlier threshold amount is updated each fiscal year -The high-cost outlier may reduce the facility's potential financial losses for costly cases
The outlier payment ensures hospitals will not experience a financial loss for the encounter
When CMS looks at recalculating the risk adjustment model, it looks back on _________________ claims for the prior year to forecast the following year's costs. outpatient fee-for-service inpatient None of these are correct.
fee-for-service
If the coder comes across a situation where the same condition is described in the medical record as being both acute and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, the coder will code both and sequence the acute (subacute) code: _________ -first. -second. -not at all. -last.
first
According to CMS, disease hierarchies address situations when there are _______________ for a particular disease and _____________________, and these data have been reported for a beneficiary. several options, Medicare eligibility multiple levels of severity, discharge disposition the admission diagnosis, discharge diagnosis multiple levels of severity, varying degrees of associated costs None of these are correct.
multiple levels of severity, varying degrees of associated costs
A ____________________ is a tool that can smooth out or normalize data over a period of time. normalization factor frailty adjustment low-income status None of these are correct.
normalization factor
The goal of ____________ is to have a process in place that will help insurance carriers provide coverage to individuals with pre-existing conditions. Accountable Care Organization third-party administration Medicare and Medicaid reinsurance and risk corridor programs
reinsurance and risk corridor programs
Selected Significant Disease (SSD) Model considers ____________ manifestations of a condition. non-urgent serious elective a patient's history of
serious
The difference between the CMS HCC and the RxHCC models is in the potential expenditure. Each model calculates total expenditures, which in the CMS-HCC model are medical services, and in the RxHCC model, the expenditures are reflective of: _____________ medical expenditures. prescription drug costs. comorbid conditions. complexity of diagnoses.
prescription drug costs.
According to CMS, Comprehensive Primary Care Plus, or CPC+, is defined as "a national advanced primary care medical home model that aims to strengthen primary care through multi-payer payment reform and care delivery transformation." True False
true
According to CMS, the "HCC risk adjustment model produces a risk score, which measures a person's or a population's health status." True False
true
If a patient has a history of a malignant neoplasm of the prostate, the coder should use a "Z" code showing this is a history and not actively being treated. -True -False
true
In an acute setting, where inpatient services are reimbursed, we see that a system called Diagnosis-Related Group (DRG) reimburses inpatient facilities based on like patients with like resource consumption. True False
true
In general, if the patient has a left below-the-knee amputation that is documented in the patient's chart, the coder should use code Z89.512 for Acquired Absence of Left Leg Below Knee. -True -False
true
The HCPCS is divided into _____________ principal subsystems. -two -three -four -five
Two
Answer the question using the POA indicators: Y = Yes N = No U = Unknown W = Clinically undetermined Scenario 3: A patient is admitted with coughing and fever. X-rays show bilateral pneumonia. She is not responding to antibiotics and is admitted to the ICU with severe sepsis. The physician documents that he is not sure whether the sepsis was present on admission or not. What is the POA indicator for the sepsis? Y N U W
W= Clinically undetermined
Answer the question using the POA indicators: Y = Yes N = No U = Unknown W = Clinically undetermined Scenario 1: A patient is treated in observation and fall out of his bed. An x-ray shows a femoral fracture. The patient is admitted as an inpatient to treat the hip fracture. What is the POA indicator for the fracture for the inpatient admission? Y N U W
Yes
A Prospective Model uses diagnostic information from _________ to predict Medicare benefit costs for the following year. a base year a prior year two prior years All of these are correct.
a base year
To ensure the accuracy and integrity of data submitted to CMS, all diagnoses codes must be documented in the medical record a result of: ________________ a discharge note. a face-to-face visit. a virtual visit. None of these are correct. both a discharge note and a virtual visit.
a face-to-face visit.
The HCC model is a Prospective Model that uses diagnostic sources because the model recognizes diagnoses from: _________ hospital inpatient settings. hospital outpatient settings. physician settings. None of these are correct. All of these are correct.
aLL hospital inpatient settings. hospital outpatient settings. physician settings.
A financial report or statement of financial position can provide information about an organization's _____________________. -liabilities -owner's equity -assets -All of these are correct. -None of these are correct.
All -liabilities -owner's equity -assets
Medicare covers beneficiaries who ________________________ and have elected to pay a premium for coverage. -are entitled to Social Security -are entitled to Railroad Retirement -have end-stage renal disease (ESRD) -are entitled to Social Security and have ESRD -Correct! All of these are correct.
All of the above -are entitled to Social Security -are entitled to Railroad Retirement -have end-stage renal disease (ESRD) -are entitled to Social Security and have ESRD
Which of the following data are used in calculating the risk scores for both the MA plans and the FFS plans? ________ Demographic data capture Frailty adjustment Diagnostic data Normalization factor
Diagnostic data
The patient has met none of his annual deductible and visits his doctor on January 1, 20XX. What is the patient's out-of-pocket responsibility? Medicare Fee Schedule Amount = $300 Annual Deductible: $185.00 -$300 -$185 -$245 -$60
$245 he patient must pay his annual deductible, which is $185.00. Then, he pays his mandated 20 percent of the Medicare fee schedule amount, which equals $60. Thus, the patient's responsibility is $245
Instructions: Use the following information to answer the question: Triad Healthcare Financial Data 12/31/2020 Cash $ 400,000 A/R 250,000 Building 1,000,000 Land 700,000 A/P 350,000 Mortgage 600,000 Revenue 2,600,000 Expenses 2,300,000 What was Triad's net income? -250,000 -400,000 -300,000 -4,900,000
$250,000 Rationale: Revenue 2,600,000-Expense 2,300,000= 300,000 net income (p. 822).
_________________________is a statement that describes in detail any symptom, problem, condition, or diagnosis that prompts the physician to ask the patient to return for a visit, or the reason the patient is in the physician's office for a visit. - Chief complaint -History of present illness -Review of systems -Medical decision-making
- Chief complaint
A practitioner should make sure that all documentation in the patient's medical record is unique to the encounter and not use: _____________ -"due to." -"in remission." -"history of." -"cut and paste."
-"cut and paste."
A practitioner should not use __________________ when describing a known active condition. -"due to" -"in remission" -"history of" -"cut and paste"
-"history of"
Over the past few years, the Centers for Medicare and Medicaid Services (CMS) has implemented some powerful tools that shift the focus from a ______________ approach to a prospective approach that looks to prevent fraud. -prospective -retrospective -"pay and chase" -None of these are correct.
-"pay and chase"
The Third Level of Appeal is established when at least _____ remains in controversy following a Qualified Independent Contractor (QIC) decision. A request for reconsideration through an Administrative Law Judge (ALJ) hearing must be filed within 60 days of receipt of the reconsideration decision. -$120 -$140 -$160 -$180
-$140
The success of a program like this one is realized in dollars, in that for every $1 spent, there is a savings of _______________ in the first year of this program. -$2 -$3 -$4 -$1
-$3
________________ are a specific patient condition that is secondary to a patient's principle diagnosis. -Complications -Comorbidities -Outliers -Transfers
-Comorbidities
Instructions: Use the following information to answer the question. The following information was abstracted from Community Hospital's balance sheet. Total assets: $25,000,000 Current assets: $4,000,000 Total liabilities: $10,000,000 Current liabilities: $5,000,000 Community Hospital is purchasing a new ambulance. The ambulance will cost $100,000, which will be depreciated at $20,000 per year for five years. Related cash inflows from reimbursements are projected to be $45,000 annually. The hospital expects to replace the vehicle when it is fully depreciated. How much is the accounting rate of return on this investment? -20% -25% -45% -100%
-25%
Instructions: Use the following information to answer the question: Triad Healthcare Financial Data 12/31/2020 Cash $ 400,000 A/R 250,000 Building 1,000,000 Land 700,000 A/P 350,000 Mortgage 600,000 Revenue 2,600,000 Expenses 2,300,000 What is Triad's total net assets on its year-end balance sheet? -250,000 -400,000 -950,000 -1,400,000
-250,000 Rationale: Assets (400,000 +250,000+1,000,000+700,000=2,350,000)=Liabilities (350,000+600,000=950,000) + net assets. 2,350,000=950,000+ net assets. Net assets = 1,400,000 (p. 814)
The certification must state that a face-to-face encounter took place within 90 days prior to the start of home care or within _____ days after the start of care. The patient must be considered to be confined to their home environment and in need of intermittent care. -10 -20 -30 -None of these are correct.
-30
Community Hospital is purchasing a new ambulance. The ambulance will cost $150,000, which will be depreciated at $30,000 per year for five years. Related cash inflows from reimbursements are projected to be $80,000 annually. The hospital expects to replace the vehicle when it is fully depreciated. How much is the accounting rate of return on this investment? -20% -33% -60% -80%
-33% Rationale: The accounting rate of returns compares the projected annual cash inflows, minus any applicable annual depreciation, divided by the initial investment or 80,000 − 30,000 / 150,000 = 33% (p. 839).
If an organization has an average daily gross patient service revenue of $230,000 along with 120 patient preregistered encounters, 150 scheduled encounters, and $100,000 in gross dollars in discharged, not final billed accounts, what is the DNFB rate? -43,5% -52.1% -2.3% -80%
-43,5%
According to CMS, ESRD occurs from the destruction of normal kidney tissues over a long period of time. Often, there are no symptoms until the kidney has lost more than _____________ of its function and is usually irreversible and permanent. -25% -50% -75% -100%
-50%
A benefit period is a time frame that is part of a hospital stay until the patient is discharged. The time after the discharge and the next admission needs to be at least _________ consecutive days since the last stay in a hospital or skilled nursing facility. -30 -60 -90 -120
-60
The Fourth Level of Appeal is when an organization or party is unhappy with the ALJ decision and may request a review by the Appeals Council. This request must be submitted within ____ days of receipt of the ALJ's decision and must specify the issues and findings that are being contested. -30 -60 -90 -120 -None of these are correct.
-60
Accountability was a focus of the PPACA, and the insurance companies were required to bring down the cost of care by spending more of the premium dollars that they collected directly on patient care. The goal was that at least ____ of all premium dollars collected from large employers were spent on healthcare services and supported quality improvement. -65% -75% -85% -95%
-85%
Which of the following purchases would most likely be considered a capital budget item? -A cost of less than $50.00, with life expectancy of 5 years -A cost of more than $50.00, with a life expectancy of 6 months -A cost of more than $1,000.00, with a life expectancy of 3 months -A cost of more than $1,000.00, with a life expectancy of 3 years
-A cost of more than $1,000.00, with a life expectancy of 3 years
What term is used to represent a difference between the budgeted amount and the actual amount of a line item that is expected to reverse itself during a subsequent period? -A permanent variance -A fixed cost -A temporary variance -A flexible cost
-A temporary variance
_____________________ is where an organization provides a service to a customer, and this customer agrees to pay for the service after it is completed. -Accounts payable -Accounts receivable -Inventory -None of these are correct.
-Accounts receivable
Services rendered and billed to customers for future payment create transactions that are posted to _____. -Accounts payable and revenue -Accounts receivable and cash -Accounts payable and accounts receivable -Accounts receivable and revenue
-Accounts receivable and revenue
Which of the following can be a primary care physician (PCP)? -Family physician -Pediatrician -Internist -Obstetrician/gynecologist -All of these are correct.
-All -Family physician -Pediatrician -Internist -Obstetrician/gynecologist
The central part of the __________________________ is to request the medical records for the patient's stay that is in question. The medical records will assist the RAC in determining if there was an overpayment or underpayment. -Automated Review -Retrospective Review -Prospective Review -Complex Review
-Complex Review
There are principles for documentation for Evaluation and Management (EM) services, and according to CMS, the nature and amount of physician work and documentation will vary based on: _________ -the type or types of service provided. -the place of service. -the patient's status. -All of these are correct.
-All of these are correct. -the type or types of service provided. -the place of service. -the patient's status.
Deposits in a bank may be guaranteed by the federal government, however ______________________ can pose a risk for losing value. -stocks -bonds -other types of securities -All of these are correct. -None of these are correct.
-All of these are correct. stocks bonds other types of securities
Which of the following is included in the LEIE online database? -Name of the excluded person -Provider type -Authority that excludes the person -All of these are correct. -None of these are correct.
-All of these are correct. -Name of the excluded person -Provider type -Authority that excludes the person
Currently, we are in a prospective payment environment and have various forms of payment, such as: __________________ -managed care. -episode-of-care. -capitation. -global payment. -All of these are correct.
-All of these are correct. -managed care. -episode-of-care. -capitation. -global payment.
Medicare abuse may include: __________________ -misusing codes on a claim. -charging excessively for products and services. -charging for prodcuts that were not medically necessary. -All of these are correct.
-All of these are correct. -misusing codes on a claim. -charging excessively for products and services. -charging for prodcuts that were not medically necessary.
The mission of the HEAT Team is to gather resources across government agencies to help prevent waste, fraud, and abuse in the Medicare and Medicaid programs, which will: _________________________ -reduce skyrocketing healthcare costs. -improve the quality of care. -highlight best practices. -All of these are correct.
-All of these are correct. -reduce skyrocketing healthcare costs. -improve the quality of care. -highlight best practices.
Community Hospital is evaluating the following three investments. Which one has the highest profitability index? -The radiology investment -The cardiology investment -The pharmacy investment -All three are equally profitable
-All three are equally profitable -The radiology investment -The cardiology investment -The pharmacy investment
Instructions: Use the following information to answer the question. The following information was abstracted from Community Hospital's balance sheet. Total assets: $25,000,000 Current assets: $4,000,000 Total liabilities: $10,000,000 Current liabilities: $5,000,000 The HIM department records copy fees as revenue. Year-to-date, the budgeted fees are $35,000 and the actual fees received are $23,000. The director may be asked to explain _____. -A favorable variance of $12,000 -An unfavorable variance of $12,000 -A favorable variance of $23,000 -An unfavorable variance of $23,000
-An unfavorable variance of $12,000
____________________ include patient encounters that fall into two categories of exams: routine adult health exam with abnormal findings and routine adult health exam without abnormal findings. -Routine visits -Chronic Care visits -Diagnostic visits -Annual Wellness visits
-Annual Wellness visits
Once an improper payment is identified, the RAC would contact the provider and notify them of an overpayment that they received. They would look to collect that amount from the provider, or an underpayment that the provider received from CMS and pay that amount to the provider. This process is called: ___________ -Automated Review. -Retrospective Review. -Prospective Review. -Complex Review.
-Automated Review.
__________ is made up of a labor-related share or portion and a nonlabor-related share or portion. -Relative weight -Base rate -Case mix -Relative value units
-Base rate
__________________ is/are a way in which the facility can choose to help a patient that is in need of services from the provider. This is not designed as a tool for people who refuse to pay; it is for people who have unplanned or unforeseen medical needs and do not have insurance or a means to pay for those services at the time of treatment. -Fee-for-service -Indigent care -Charity care -Both indigent care and charity care -None of these are correct.
-Both indigent care and charity care
A Coordinated Care Plan (CCP) includes a network of providers that are under a contractual arrangement to deliver the benefit package that is approved by: _______ -CMS. -NCQA. -ACOs. -HEDIS.
-CMS.
__________ is not based on a specific procedure or hospital stay, as it is based on a per-member-per-month (PMPM) methodology. -Capitated payment -Block payment -Transfer payment -Bundled payment
-Capitated payment
________________________ 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. -Charge capture -Claims processing -Claims scrubbing -Chart audit -Charge Description Master
-Charge Description Master
_______________________ will show who was in contact with the patient, what services were delivered, and any other clinical information that can help in the decision-making process for the patient while in the facility. -Patient accounts -Clinical documentation -Health information management -Administration
-Clinical documentation
The purpose of the _________________________________ of the PPACA is to provide American citizens with a new option to finance long-term care services. -Community Living Assistance Services and Supports Act -Transparency and Program Integrity -Healthcare Workforce -Revenue Provisions
-Community Living Assistance Services and Supports Act
_______________________ is a very important part of the episode-of-care payment method. It requires that the providers of care, along with the plans, be as precise as possible in projecting expenditures in order to negotiate a contract that will cover the costs involved in treating the members of the plan. -Contract management -Capitation -Block payment -Utilization management -None of these are correct.
-Contract management
The PPACA will offset the premiums for healthcare insurance by providing the _______________ tax cuts that will allow the families and small businesses to benefit from more affordable healthcare coverage. -upper class -lower class -middle class -people on Medicare and Medicaid
-Correct! middle class
The following are the most common reasons for claim denials except _____. -Billing noncovered services -Lack of support for medical necessity -Untimely filing -Coverage not in effect for date of service
-Coverage not in effect for date of service
Dr. Blake's administrative assistant purchased office supplies at an office supplies store and charged the purchase to the doctor's account. The journal entry used to record this transaction is _____. -Debit office supplies; credit accounts receivable -Debit accounts payable; credit office supplies expense -Debit office supplies expense; credit accounts payable -Debit accounts receivable; credit revenue
-Debit office supplies expense; credit accounts payable
A financial counselor assumes responsibility for which of the following? -Ensuring appropriate and timely care is provided -Identifies barriers to patient progression through healthcare services -Connects with patients after they leave the provider -Determines sources of payment for healthcare services rendered
-Determines sources of payment for healthcare services rendered
Determinations of medical necessity reflect the efficient and cost-effective application of patient care for which of the following? -Positive patient interactions -Previous medical conditions -Physician restrictions -Diagnostic testing
-Diagnostic testing
Which of the following payment methods reimburses healthcare providers in the form of lump sums for all healthcare services delivered to a patient for a specific illness? -Managed fee-for-service -Capitation -Episode-of-care -Point of service
-Episode-of-care
_________________________ is where financial statements demonstrate the important financial relationships of the organization itself. -Relevance of information -Faithful representation -Complete representation -Usefulness for decision
-Faithful representation
A hospital that performs transplant surgery may not acquire cadaver kidneys by excising them from cadavers located in its own hospital. They must accomplish this through arrangements with a freestanding organ procurement organization (OPO) that provides cadaver kidneys to any transplant hospital. -True -False
-False
For a home care patient being discharged from the hospital, the discharge planning evaluation must be present in the patient's medical record, however, the hospital does not need to discuss the planning process and evaluation with the patient and/or family members. -True -False
-False
If an excluded person violates the imposed exclusion, furnishes items or services to a Federal Healthcare Program beneficiary, and submits a claim for payment of these services, the excluded person may be subject to CMP of $10,000 for all claimed items or services furnished during the period that the person was excluded. -True -False
-False
If while on hospice a Medicare beneficiary is in need of or requires care or hospitalization for treatment that is not related to hospice service, Medicare will not pay for this treatment. -True -False
-False
In the agreement/attestation statement signed by a provider, it agrees to charge Medicare beneficiaries for any services which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program. -True -False
-False
Medicare Part B covers services and supplies, such as drugs and biologicals, that are usually self-administered by the patient. -True -False
-False
The federal/state entitlement program that came out of the Title XIX of the Social Security Act that pays for medical assistance for individuals with low income is called Medicaid, which became law in 1965 and is funded only by the individual state governments. -True -False
-False
The maintenance of the CDM is a single disciplinary activity and requires one person or department to have oversight. -True -False
-False
When a payer rejects a claim for payment, organization staff must determine the reason for denial. If the denial was deemed due to eligibility determination, what process in the revenue cycle failed to operate as intended? -Front-end process -Middle process -Back-end process -Support services
-Front-end process
_________________ establishes "the measurement of economic activity, time when such measurements are to be made and recorded, disclosures surrounding this activity, and preparation and presentation of summarized economic information in the form of financial statements. -A financial statement -FASAB -GAAP -All of these are correct.
-GAAP
________________________ means that the payment is based on the payment locality. -Conversion factor -MP -Work -PE -GPCI
-GPCI
In Medicare's resource-based relative value scale payment system, which factor adjusts payments to physicians and health professionals for price differences among various parts of the country? -Practice RVU -Geographic practice cost index -Malpractice RVU -Conversion factor
-Geographic practice cost index
A ______ occurs when radiological and other procedures that include professional and technical components are paid as a lump sum to be divided between the physician and the healthcare facility. -Global payment -Professional payment -Unbundled payment -Fee-for-service payment
-Global payment
In the home health prospective payment system, the resource groups are called ____________ instead of DRGs. -HHRG -HIPPS -APR -both HHRG and HIPPS -None of these are correct.
-HHRG
____________________ is designed for an acute care inpatient setting, and the single payment does not include payment for any professional services that are provided during the patient's hospital stay. -IPPS -IPF PPS -IRF PPS -Both IPPS and IRF PPS -All of these are correct.
-IPPS
The primary disadvantage of cost analysis of asset acquisition using payback period is that payback period _____. -Is difficult to explain to non-financial managers -Is difficult to calculate -Ignores the time value of money -Ignores the historical cost of the asset
-Ignores the time value of money
Which financial statement reflects the extent to which an organization's revenues exceed its expenses? -Balance sheet -Statement of cash flow -Statement of retained earnings -Income statement
-Income statement
Medical severity diagnosis-related groups (MS-DRGs) represent a prospective payment system implemented by the CMS to reimburse hospitals a predetermined amount for services provided to ______. -Inpatients -Outpatients -Inpatients and outpatients -Home health and outpatients
-Inpatients
________________________ is the next step in the registration process; it is a critical element and can sometimes be electronic. -Patient scheduling -Insurance verification -Prior authorization -Financial counseling
-Insurance verification
These groups manage the care delivered by multiple providers and multiple facilities. The _______ will generally provide the full spectrum of care from physician services, acute care, ambulatory care services, and services of a skilled nursing facility. -IDS -IPO -GPWW -None of these are correct.
-Integrated Delivery Systems
If a home health agency provides four visits or less in an episode, they will be paid a standardized per visit payment instead of an episode payment for a 60-day period, which is referred to as a: _________________ -Partial Episode Payment. -Low Utilization Payment. -Transfer Type 1. -Transfer Type 2. -None of these are correct.
-Low Utilization Payment.
__________________________ covers all immunosuppressive drugs following a covered transplant in an approved facility based on the Criteria for Medicare Coverage of Heart Transplants. -Medicare Part D -Medicare Part C -Medicare Part A -Medicare Part B
-Medicare Part B
_________________ started by providing access to prescription drug discount cards for no more than $30.00 annually. Then, the program transitioned into providing subsidized access to prescription drug coverage. -Medicare Part A -Medicare Part B -Medicare Part C -Medicare Part D
-Medicare Part D
After transplantation, all physician services rendered to the transplant recipient are billed to the _____________________ with all other services during the stay. -Medicaid program -commercial insurance program -Medicare program -None of these are correct.
-Medicare program
The term _________________ is used by a beneficiary to cover healthcare services that are not covered by Part A or B. These policies must meet federally imposed standards and are offered by Blue Cross and Blue Shield and various other commercial health insurance companies. -Medicare Part A -Medicare Part B -Medicare Part C -Medicare Part D -Medigap
-Medigap
Payment status indicator _________ is where there is no reimbursement under OPPS. -N -S -F -V -X
-N
The purpose of many key performance indicators involve measuring, monitoring, and trending efforts along with setting appropriate goals. Which of the following MAP Key measure results in a value to indicate revenue cycle process efficiency? -Clean claim rate -Net days in A/R -Net days in credit balance -Point of service cash collections
-Net days in A/R
According to CMS, there are three categories that are related to targeted populations. These include all of the following, except: _____________ -Chronic Conditions SNPs. -Dual-eligible SNPs. -Institutionalized SNPs. -Non-chronic Condition SNPs.
-Non-chronic Condition SNPs.
_____________ is a financial obligation supported by a contract and has a time frame for repayment; it can be associated with a large purchase or a loan when an organization uses some of their assets as collateral. -Accounts payable -Notes payable -Both accounts payable and notes payable -None of these are correct
-Notes payable
Key objectives of the revenue cycle middle processes include all of the following except _____. -Obtaining preauthorization for services -Reconciling charges for services provided -Accurate, complete, and timely documentation and coding -Identifying separately billable items
-Obtaining preauthorization for services
_______________________ is the overhead and costs to operate the practice. -Conversion factor -MP -Work -PE -GPCI
-PE
_____________________ is the first point of contact with the patient. -Patient scheduling -Insurance verification -Prior authorization -Financial counseling
-Patient scheduling
Which of the following does not describe capitation? -Provides all contracted healthcare services needed by an individual -Individual enrollee or third-party payer pays a fixed premium for the covered group -Payment for each medical service is usually based on the actual charges of the provider -Contract stipulates exactly which healthcare services are covered and which ones are not
-Payment for each medical service is usually based on the actual charges of the provider
_________________________________ are "the collection of the portion of the bill that is likely the responsibility of the patient before the provision of services." -Point-of-service collections -Retrospective collections -Claim submissions -Consumer-driven health plans
-Point-of-service collections
Which relative value unit takes into account the operational costs of delivering healthcare services, such as rent, wages of technical personnel, supplies, and equipment? -GPCI -Professional liability insurance RVU -Work RVU -Practice expense RVU
-Practice expense RVU
The __________ health record is comprised of a problem list, the database or the history and physical exam and initial lab findings, the initial plan of what tests or treatments the patient will receive during their stay, and progress notes that are organized so that every member of the healthcare team can easily follow the course of the patient's treatment. -Integrated -Source-Oriented -Paper -Problem-Oriented
-Problem-Oriented
The agency or facility providing the care to the patient will be responsible for payment of the supplies that are covered under Part B, as they are covered under the payment for: ____________ -Prospective Payment System (PPS). -Diagnosis-Related Group (DRG). -Ambulatory Payment Classification (APC). -Home Health Resource Groups (HHRG).
-Prospective Payment System (PPS).
Which of the following reimbursement methods pays providers according to charges that are calculated before the healthcare services are rendered? -Fee-for-service reimbursement -Prospective payment -Retrospective payment -Resource-based payment
-Prospective payment
The ___________________________ are MA plans offered to a society that is limited to only the members of the society. -Employer Group Health Plans -Private Fee-for-Service Plans -Medicare Medical Savings Account Plans -Religious Fraternal Benefit Plans
-Religious Fraternal Benefit Plans
Understanding adjustments in payment to the provider and then utilizing the information to determine subsequent revenue audit and recovery efforts initiate from which of the following? -Remittance advice -Claim form 837 -Adverse determination -Accounts receivables
-Remittance advice
Which of the following is true about the advance beneficiary notification of noncoverage? -Estimates patient's financial out-of-pocket financial responsibility -Supports patients with financial assistance applications -May be issued when an inpatient service has been regarded non-covered due to medical necessity -Required to be issued when outpatient service is considered not likely to be covered by Medicare
-Required to be issued when outpatient service is considered not likely to be covered by Medicare
_____________________ is the income that is produced through the sales function of an organization to sell products and/or services to customers; it is the amount that the customers will pay for these products and/or services. -Revenue -Accounts receivable -Net income -None of these are correct.
-Revenue
Which of the following is most applicable to describing utilization management functions? -Begins only after patient admission -Provides criteria to monitor for the continued appropriateness of the supplies and patient convenience items -Screens for the appropriate use of hospital services and resources -Applies criteria to determine medications that should be prescribed
-Screens for the appropriate use of hospital services and resources
Carrier jurisdiction for claims involving individuals who are part of the Railroad Retirement Beneficiary includes those who are entitled to both ______________ and railroad retirement benefits. -Medicare -Medicaid -Blue Cross and Blue Shield -Social Security
-Social Security
In a(n) __________, the HMO will directly employ the physicians and various other healthcare professionals to provide healthcare services to their members. -Group Model HMO -Staff Model -Network Model HMO -Integrated Delivery System -Exclusive Provider Organization
-Staff Model
Determinations of medical necessity must reflect the efficient and cost-effective application of patient care, including all of the following except _____. -Diagnostic testing -Levels of hospital care -Therapies and procedures -Supplies used for patient treatment
-Supplies used for patient treatment
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (also known as Welfare Reform) brought about many changes, which included the implementation of: -HMO -Temporary Assistance for Needy Families (TANF) -Progrms of All-inclusive Care for the Elderly (PACE) -Children's Health Insurance Program (CHIP)
-Temporary Assistance for Needy Families (TANF)
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. -True -False
-True
The Cost-to-Charge Ratio (CCR) is applied to the covered charges for a case to determine whether the costs of a case exceed the fixed-loss outlier threshold. -True -False
-True
Dr. Phillips, Dr. Patel, and Dr. Blankley are all gynecologists. They work together under the name Community Women's Center. Dr. Phillips owns 50 percent of the business. Dr. Patel and Dr. Blankley each own 25 percent of the business. The profits from their business flow directly to their personal tax returns. The doctors would like to bring another practitioner into the business as an owner. Which of the following actions must take place in order to bring a new owner into the business? -The existing owners must each sell some of their shares to the new owner. -The existing owners must dissolve the existing partnership and make a new partnership agreement. -The new practitioner must come in as an employee. -The Board of Trustees must authorize a resolution to accept a new partner.
-The existing owners must dissolve the existing partnership and make a new partnership agreement.
Under the APC system, multiple procedures performed during the same surgical encounter are reimbursed at which of the following rates? -All significant procedures receive full (100 percent) payment. -The procedure in the highest APC receives full payment and the remaining procedures receive half (50 percent) payment. -The procedure in the lowest APC receives full payment and the remaining procedures receive half (50 percent) payment. -The procedure in the highest APC receives full payment and the remaining procedures receive seventy-five (75 percent) payment.
-The procedure in the highest APC receives full payment and the remaining procedures receive half (50 percent) payment.
Which of the following statements are a most appropriate reflection about national and local coverage determinations (NCDs and LCDs)? -They define the standard of care that must be used to treat the patient's condition. -They define the specific International Classification of Diseases (ICD) diagnosis codes that support medical necessity. -They exist for all procedures and services that are provided to patients. -They do not directly affect whether payment is received for the services provided.
-They define the specific International Classification of Diseases (ICD) diagnosis codes that support medical necessity.
Why are revenue audit functions necessary in organizations? -To determine if reimbursement received is accurate based on the terms of the payer contract or agreement for all payment relationships -To identify all individual claims in which an appeals process should be initiated. -To determine if claims are missing required data elements for submission. -To determine the best approach to focusing efforts on the largest denials.
-To determine if reimbursement received is accurate based on the terms of the payer contract or agreement for all payment relationships
In _________________________, a transfer between IPPS hospitals, the transferring hospital will be paid a per diem rate for the days that the patient spends at the facility. -Transfer Type 1 -Transfer Type 2 -Transfer Type - special payment transfer -None of these are correct.
-Transfer Type 1
________________________ is a transfer that takes place between a hospital and a facility that is excluded from IPPS. -Transfer Type 1 -Transfer Type 2 -Transfer Type - special payment transfer -None of these are correct.
-Transfer Type 2
What approach involves the area providers should focus on when building patient relations and customer service in the revenue cycle related to the patient's financial obligations? -Consumer-centric approach -Patient engagement approach -Transparency approach -Payment variance approach
-Transparency approach
A supplier is a physician or other practitioner, or an entity other than a provider who furnishes healthcare services under Medicare, and must meet certain requirements as outlined in the Medicare Program Integrity Manual. -True -False
-True
According to CMS, in order for a patient to be eligible for home health services under Medicare Parts A and B, the physician needs to attest that the patient requires home care and is homebound. -True -False
-True
An example of non-operating revenue is investment income and the money generated from the gift shop that is run by the volunteer organization in the hospital. -True -False
-True
Any payments from a state Medicaid program to a healthcare provider are considered as "Payment in Full." -True -False
-True
Each HCPCS code is assigned to only one Ambulatory Payment Classification (APC), however there can be an unlimited number of APCs per encounter for a single beneficiary. -True -False
-True
In a Transfer Type 2, the transferring facility is paid for the full admission, and any outlier calculations will apply for the full admission. The receiving facility will receive payment based on the type of payment system that the facility falls under in the Medicare payment system. -True -False
-True
In the provider agreement between CMS and the provider, the provider agrees to promptly refund any money that they incorrectly collected from the Medicare beneficiary. - True -False
-True
In the transfer process, to determine the per diem rate, the facility will: take the total cost, divide it by the Geometric Mean Length of Stay (GMLOS), multiply by the total days spent at the transferring facility, and then add one. -True -False
-True
Medicare Part B is financed by monthly premiums from those beneficiaries who voluntarily enroll in the program. The funds generated by the collection of premiums are deposited in a separate account known as the Federal Supplementary Medical Trust Fund. -True -False
-True
People with Amyotrophic Lateral Sclerosis (ALS) were given eligibility for Medicare, without having to wait for the customary 24-month waiting period. -True -False
-True
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a comprehensive healthcare program where the Veterans Affairs (VA) shares the cost of care for covered services and supplies. -True -False
-True
At Community Health Services, each budget cycle provides the opportunity to continue or discontinue services based on available resources so that every department or activity must be justified and prioritized annually in order to effectively allocate resources. Community Health uses what type of operational budget? -Activity-based -Zero-based -Flexible -Fixed
-Zero-based
If kidney and pancreas transplants are performed simultaneously, the claim should contain: ______________________ -a diabetes diagnosis code. -a renal failure diagnosis code. -a hypertensive renal failure diagnosis code. -a diabetes diagnosis code and a renal failure diagnosis code or one of the hypertensive renal failure diagnosis code. -only a diabetes diagnosis code and a hypertensive renal failure diagnosis code.
-a diabetes diagnosis code and a renal failure diagnosis code or one of the hypertensive renal failure diagnosis code.
A financial relationship includes both ownership and investment interests, along with compensation arrangements that include contractual arrangements between a ____________________ and ______________________ for physician services. -a hospital and a Health Maintenance Organization (HMO) -a physician and a Physician-Hospital Organization (PHO) -a hospital and a physician -a Managed Care Organization (MCO) and a PHO
-a hospital and a physician
When an organization uses the ___________ accounting method, it will be a better indicator of future cash flows and overall performance than using current cash receipts and disbursements. -accrual -financial -cash -general
-accrual
There is an important factor in the __________ method for the healthcare administrator to understand: the organization will account for revenue in the period it was realized even though it was not paid for yet. -financial accounting -managerial accounting -accrual accounting -cash basis
-accrual accounting
The Advance Beneficiary Notice (ABN) cannot have italics or any font that is difficult to read and must be: ______________________ -at least 12-point font size. -in dark ink. -legibly handwritten. -All of these are correct. -None of these are correct.
-all of these are correct -at least 12-point font size. -in dark ink. -legibly handwritten.
Overall, the healthcare administrator needs to be an expert in ___________________________ to ensure the future of the facility, their ability to provide quality care, and their potential to be appropriately reimbursed for the care delivered. -revenue cycle management -budgeting and finance -operations -compliance -all of these are correct
-all of these are correct -revenue cycle management -budgeting and finance -operations -compliance
According to the risk adjustment program, diagnosis codes need to be reported: _________________ -monthly. -quarterly. -semi-annually. -annually.
-annually.
The ________________ shows, at a certain point in time, the impact that all the organization's transactions have had on the company's assets, liabilities, and owner's equity. -balance sheet -statement of cash flows -income statement -general ledger
-balance sheet
Healthcare facilities need to make sure that they are following ________________________ to ensure that all HCPCS codes are consistent in their descriptions. -Best Practices -Coding Clinic -Federal Register -both Best Practices and Coding Clinic -None of these are correct.
-both Best Practices and Coding Clinic
The __________ component of a compliance program will help to evaluate if individuals are properly carrying out their responsibilities and claims are submitted appropriately. -auditing -monitoring -both auditing and monitoring -None of these are correct.
-both auditing and monitoring
In the past, in the fee-for-service approach to managing the financial side of healthcare reimbursement, it was: _______________ -fragmented. -contiguous. -departmentalized. -seamless. -both fragmented and departmentalized.
-both fragmented and departmentalized.
The PPACA looks to save consumers money by __________ to those providers that take care of the low-income patients or may be a disproportionate-share hospital. -promoting innovation -increasing reimbursement for services -extending drug discounts -both promoting innovation and extending drug discounts
-both promoting innovation and extending drug discounts
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: _______________________ -reduces accounts receivable. -increases the cash account. -allows the biller to write off any nonpayment or short payment. -both reduces accounts receivable and increases the cash account.
-both reduces accounts receivable and increases the cash account.
There are areas of the country that are in need of primary care physicians, nurses, physician assistants, mental health providers, and dentists. The PPACA will address these issues by making available ______________ that will help attract clinicians to these areas. -scholarships -reduced room and board -loan repayment programs -both scholarships and loan repayment programs
-both scholarships and loan repayment programs
The costs in a facility can be: _____________________ direct costs. -variable costs. -fixed costs. -indirect costs. -both variable costs and fixed costs.
-both variable costs and fixed costs.
In 2013, the PPACA focused on improving preventative healthcare coverage for the Americans receiving preventative care. It also looked at expanding the use of: ___________________ -fee-for-service payments. -capitations. -retrospective payments. -bundled payments to providers.
-bundled payments to providers.
The assignment of ICD-10-CM codes are entirely based on ___________________, and the medical records must be authenticated. -the EHR -clinical documentation -reason for visit -all diagnostic tests ordered
-clinical documentation
The middle process "represents the intersection of ________________ and billing". -financial management -clinical practice -admissions staff -insurance verification
-clinical practice
A(n) _____________________ is one who has received professional services from the physician, qualified healthcare professional, or another physician or qualified healthcare professional of the same specialty and subspecialty who belongs to the same group practice, within the past three years. -new patient -established patient -transfer patient -None of these are correct.
-established patient
The goal of the PPACA was to _______________, and at the same time, reduce the medical expenditures that Medicare has been facing over the years. -expand the coverage of health insurance -increase medical expenses -remove the burden of coverage for commercial payers -None of these are correct.
-expand the coverage of health insurance
The Case Manager helps the patient identify appropriate out-of-network providers that fit the patient's needs and to ensure the continuum of care for the patient is uninterrupted by having to change providers. -True -False
-false
The Criminal Health Care Fraud Statute is found in 18 U.S. Code Section 1347 and prohibits knowingly and willfully executing or attempting to execute a scheme to defraud only a Medicare program. -True -False
-false
The typical _______________ payment structure is where a provider will bill for all services rendered to the third-party payer after the services have been provided and then the third-party payer, retrospectively, will pay the provider. -fee-for-service -episode-of-care -block payment -capitation
-fee-for-service
The budget cycle is generally related to the __________________ of a company. -calendar year -quarterly period -fiscal year -monthly period
-fiscal year
The appeals process consists of ____________ levels; each level must be completed for each claim at issue prior to proceeding to the next level. -four -three -five -six
-five
A _____________ budget is created based on productivity that is projected according to historical data. -flexible -fixed -activity-based -zero-based
-flexible
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. -back-end process -middle process -front-end process -silo approach
-front-end process
The _____________________ methodology can be applied to procedures that are associated with technical components. This is a lump-sum payment that can be distributed among all the physicians who either performed the procedure or interpreted the results of the procedure. -retrospective payment -block payment -global payment -capitated payment
-global payment
ABNs given to a patient or authorized representative who is under _______________ cannot be considered a proper notice. -great duress -a non-emergent situation -both great duress and a non-emergent situation -None of these are correct.
-great duress
Most Integrated Delivery Systems (IDSs) are comprised of multiple facilities that can provide care along the continuum of care for the patient and their family. They include all of the following, except: _____________ -physician's offices. -ambulatory surgical centers. -outpatient clinics. -homecare agencies.
-homecare agencies.
The ____________________________ is intended to demonstrate how much money a company is making or losing. It does so by subtracting all of the costs of production of goods that have been sold during the period and other expenses of running the company from the revenues generated from sales. -cost control -statement of cash flows -balance sheet -income statement
-income statement
The regulations surrounding the calculation of this additional payment to hospitals are to offset the costs of medical education, known as the: ______________ -indirect medical education adjustment. -disproportinate share adjustment. -cost of living adjustment. -high-cost outlier adjustment. -transfer case adjustment.
-indirect medical education adjustment.
The PPACA stops insurance companies from canceling an individual's coverage just because they made a mistake on their insurance application. This protection applies to all health plans for those who get coverage _____________. -individually or through an employer. -through an employer only. -individually only. -None of these are correct.
-individually or through an employer.
The PPACA allows _______________ to take more control and make better healthcare decisions. -case managers -insurance companies -individuals -employers
-individuals
The responsibility of the SEC is to ____________ and ____________ federal securities laws, issue new and amend existing rules, oversee the inspection of securities firms, oversee private regulatory organizations, and coordinate regulations with federal, state, and foreign authorities. -interpret, enforce -initialize, revise -audit, edit -oversee, govern
-interpret, enforce
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: ______________ -location-wide scheduling system. -order tracking and management system. -registration quality assurance tools. -online third-party eligibility. -None of these are correct.
-location-wide scheduling system.
Equipment is considered to be a _________________, and with some equipment being at a lower price, it is up to the individual organization as to how they record the equipment. -short-term liability -long-term liability -short-term asset -long-term asset
-long-term asset
The American College of Medical Quality has defined ________________ as "accepted healthcare services and supplies provided by healthcare entities, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with applicable standard of care." -medical necessity -utilization management -managed care -preventative care
-medical necessity
The volume of diagnosis codes that can be tracked is not limited to four or ____________ and must be submitted each calendar year. -8 -9 -10 -11 -12
12
Which of the following demographic factors influence risk scores? Sex of the beneficiary Disability status Original reason for entitlement All of these are correct None of these are correct.
All of these are correct Sex of the beneficiary Disability status Original reason for entitlement
The objective of effective financial reporting is to provide information in a ____________ manner that will assist in making decisions regarding the allocation of resources for the organization. -timely -efficient -both timely and efficient -None of these are correct.
Both timely and effecient
When a patient has a status of receiving dialysis and is actively receiving or compliant to the regimen of dialysis, the Dialysis Center will submit information on form _________, and the information contained on this form will supply information to CMS. CMS 1500 CMS ABN CMS-2278 UB04 None of these are correct.
CMS-2278
The _______________ is a uniform coding system comprised of descriptive terms and codes that are primarily used to identify medical services and procedures that are furnished by physicians and other healthcare professionals. -ICD-9 -HIPPS -CPT -ICD-10
CPT
Which of the following describes the clinical details or a patient's reason for seeking care from a provider? Diagnosis code Health insurance claim number Provider type Service from and to dates
Diagnosis code
The term "Late Effect" is a residual effect or a condition produced, before the acute phase of an illness or injury has terminated. -True -False
False-General Coding Guidelines
____________________________ is a standardized survey and data collection tool that has been used since 2006. The goal of this program is to measure the patient's perspective of the hospital care that was received. HIPPS HCAHPS HIPAA Both HIPPS and HIPAA
HCAHPS
Which of the following code set(s) is utilized in the RBRVS prospective payment system? -HCPCS/CPT -ICD-10-CM/PCS -Both code sets -None of the above
HCPCS/CPT
_________________________ is fully responsible for the soft coding of the inpatient medical records . -Patient Accounts -Clinical Documentation -Health Information -Management Administration
Health Information Mangement
Which of the following is the beneficiary's insurance identification that is issued by the Social Security Administration or the Railroad Retirement Board? Provider type Service from and to dates Diagnosis code Health insurance claim number
Health insurance claim number
The _________________, which was created by the Affordable Care Act, is a delivery and payment incentive model that is using home-based primary care teams. These teams are focused on improving health outcomes and ultimately reducing healthcare costs for Medicare beneficiaries who have chronic conditions. Patient Centered Medical Home Accountable Care Organization Physician Hospital Organization Independence at Home Demonstration project
Independence at Home Demonstration project
To select a code in ICD-10-CM the coder will be guided by the instructional notations that appear in both the ____________ and the _____________. -Volume 1, Volume II -Index, Tabular List -alpha, Volume III -diagnosis, procedures
Index, Tabular List
The content of the ______________________ is arranged in strict chronological order. The order of the record is determined by the date the information was entered, or the date of the service that gives the sequence of the care that the patient received during their stay. -Integrated -Source-Oriented -Paper -Problem-Oriented
Integrated
__________ covers "acute myocardial infarction (AMI) 30-day mortality rate, heart failure (HF) 30-day mortality rate, pneumonia (PN) 30-day mortality rate, complication or patient safety for selected indicators (composite), central line-associated blood stream infection." Clinical Process of Care Domain Patient Experience of Care Domain Outcome Domain Efficiency domain
Outcome Domain
___________________________ provides accessible, continuous and coordinated, family-centered care to high-need populations under which care management fees are paid to persons performing services as personal physicians and incentive payments are paid to physicians participating in practices that provide such care. PCMH ACO HCAHPS VBP P4P
PCMH
The HCC risk adjustment model is used to adjust the payments that are made for ________________ benefits that are offered by Medicare Advantage plans and PACE organizations. Part B Part C Part A both Part A and Part B
Part C
The overall success of this department is predicated on both the accuracy of the charge description master and the clinical staff who are recording the transactions. -Patient Accounts -Clinical Documentation -Health Information Management -Administration
Patient Accounts
The ____________________________ covers "nurse communication, doctor communication, hospital staff responsiveness, pain management, medicine communication, hospital cleanliness and quietness, discharge information, and overall hospital rating." Clinical Process of Care Domain Patient Experience of Care Domain Outcome Domain Efficiency Domain
Patient Experience of Care Domain
________________________ is where the data are captured and are different for each year. Performance period Calendar year Fiscal year Baseline period
Performance period
Which of the following identifies the reason for the risk adjustment based on the place of care? Diagnosis code Health insurance claim number Provider type Service from and to dates
Provider type
_______________________ will enhance public accountability of the hospital as the healthcare delivery model is becoming more and more transparent. Survey Public reporting Public accountability Less transparency
Public reporting
Which of the following clearly identifies when a patient received care from the organization? Admission date and procedure date Admission date Discharge date and discharge status Service from and to dates
Service from and to dates
If a patient is admitted to an observation unit in a hospital for a medical condition and either does not improve or the condition worsens and is then admitted to the hospital as an inpatient, the coder will use the principal diagnosis as the condition that led to the actual hospital admission. -True -False
True
Modifiers are two-digit alpha or alphanumeric codes. A modifier is designed to give Medicare and other third-party payers additional information needed to process a claim. -True -False
True
The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reasons for visits in all healthcare settings. -True -False
True
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." -True -False
True
To be able to effectively code a medical record for a hospital stay or visit to a facility, the entries must be complete and contain sufficient information to identify the patient; support the diagnosis and condition; justify the care, treatment and services; document the course and results of care, treatment, and services; and promote continuity of care among providers. - True -False
True
To be an eligible beneficiary to participate in the Independence at Home Demonstration program, the beneficiary must have: __________________ two or more chronic conditions. health coverage from a Managed Care Medicare Plan. No need for assistance with walking, bathing, or feeding. had an elective inpatient hospital admission within the last 12 months.
two or more chronic conditions.
