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86 Cards in this Set
- Front
- Back
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What is the first component in the revenue cycle?
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Preclaims submission activities -
patient registration and case management areas. collecting the patient's and responsible parties' information completely and accurately for determining the appropriate financial class, for educating the patient about his or her ultimate financial responsibility for services rendered, for collecting waivers when appropriate, and for verifying data prior to procedures or services being performed and submitted for payment |
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How are charges for healthcare at all of the points of services collected and reported to the appropriate patient account for entry onto the provider's claim?
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electronically at point of service or paper based charges on charge tickets, superbills, or encounter forms
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What is the function of scrubbers in the claims processing component of the revenue cycle?
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they look for and edit inaccurate information or missing information before the claim is submitted to billing
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List the basic data elements of a CDM, identifying which data elements are hospital-specific and which are nationally recognized.
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Hospital specific - charge codes, department numbers, descriptions, and charges
Nationally specific - HCPCS codes, revenue codes |
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Discuss how NCDs are different from LCDs.
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NCD's tell what services are covered or not covered.
LCD's tell how the covered services are deemed medically necessary. |
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Healthcare facilities should design key performance indicators so that they _________________.
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can be measured to gauge performance improvement.
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Identify one MAP KPI and identify the revenue cycle component it represents.
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*Category - Patient access
*Measure - Point of service (POS) cash collection *Purpose - Trending indicator of POS collection efforts *Value - Indicates potential exposure to bad debt, accelerates cash collections, and can reduce collection costs |
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What are three benefits of an integrated revenue cycle?
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*Reduced cost to collect
*Performance consistency *Coordinated strategic goals |
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What system is typically used to audit outpatient Medicare claims?
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The Medicare Outpatient Code Editor (OCE)
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In MS-DRG relationships reporting, MS-DRG families are examined for ________________.
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MCC's and CC's
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Which provider order entry system is usually more reliable, paper-based or electronic? Why?
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Electronic. The paper system leaves more room for error because charges can posted to the wrong patient's account, digits can be transposed during data entry, and backlogs can occur when data entry clerks are absent or pulled off task.
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What are two sources of new charge description master codes?
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One source of new codes is the CMS release of updates to codes and billing guidance;
the other is performance of new services at the healthcare provider that require line items to be added to the system. |
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What risk areas are concerns when the charge description master is not properly maintained and revised?
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compliance violations and lost reimbursements, Over payment, Underpayment, Undercharging for services, Claims Rejections, Fines, Penalties
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How has HIPAA changed claims processing?
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under HIPAA is the transactions rule that identifies eight electronic transactions and 6 code sets.
This rule ensures that all providers, third party payers, claims clearinghouses, and so forth use the same set of codes to communicate coded health information. This supports standardization and Administrative simplification. |
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What are two roles of electronic data interchange (EDI) in claims processing?
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To make sure the EOBs and the MSNs are provided to the facility
EDI reports claim rejections, denials, and payments to the facility |
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List ways that discrepancies between submitted charges and paid charges are reconciled by the provider.
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The ways that discrepancies between submitted charges and paid charges can be reconciled is by the provider contacting the patient to collect the outstanding deductible or copayment.The facility needs to determine whether the claim can be corrected and resubmitted, if it cannot the facility has to write it off or make an adjustment on the patients account. When batches of EOBs, MSNs, and RAs are received via the 835A or 835B electronic format, accounting personnel check the amount owed by the patient (listed as not covered on the EOB or MSN), and collections personnel contact the patient to collect deductibles and copayments.
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How do providers decide what optimal performance is for units of their facility?
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Providers define optimal performance for units of the facility by establishing key performance indicators (KPI) which represent the areas that need to be improved. And by setting a standard for each indicator which can be measured to gauge performance improvement.
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Facility B just completed an analysis of its alarmingly high balance of unpaid claim amounts. What are some key performance indicators a provider's RCM team could use to learn the reason(s) for the surge in unpaid balances?
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Some key performance indicators a provider's RCM team could use to learn the reasons for the surge in unpaid balances could be the days from discharge to coded, the percentage of denials from the third party payers, percentage of late charges, percentage of returned claims for corrections.
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Describe at least three sources of errors that cause claim denials.
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*Invalid procedure
*Invalid revenue code *The code is not recognized or service unit out of range for procedure and data entry mistakes |
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True/False
Use of the charge description master has made manual coding by HIM coders obsolete. |
False
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Which of the following is NOT a function area of the revenue cycle?
*Cafeteria *Patient financial services *Admitting *Medical record coding |
Cafeteria
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The term "soft coding" refers to:
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CPT codes that are coded by the coders
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Which type of compliance guidance is used by Medicare to communicate policies and procedures for the specific prospective payment systems' manuals?
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CMS Program Transmittals
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True/False
There are nationally recognized rules regarding the use of charge descriptions for CPT codes in the CDM. |
False
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Scrubbers are used by hospitals to identify which of the following errors that can cause claims rejections or denials?
*Incompatible dates of service *Nonspecific or inaccurate diagnosis and procedure codes *Lack of medical necessity *All of the above |
All of the above
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The remittance advice is provided to which party?
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Facility
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In a typical acute-care setting, Aging of Accounts reports are monitored in which revenue cycle area?
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Accounts receivable
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Which type of compliance guidance is used by Medicare to describe the circumstances under which specific medical supplies, services, or procedures are covered nationwide by Medicare.
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National Coverage Determinations
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In a typical acute-care setting, Patient Education of Payment Policies is located in which revenue cycle area?
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Pre-claims submission
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Which of the following is not a benefit of an integrated revenue cycle?
*Reduced cost to collect *Separation of physician practices *Performance consistency *Coordinated strategic goals |
Separation of physician practices
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Which of the following CDM data elements is nationally recognized?
*Department code *Charge code *Charge *Revenue code |
Revenue code
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What is the name of the notice sent after the provider files a claim that details amounts billed by the provider, amounts approved by the payer, how much the payer paid, and what the patient must pay?
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EOB
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In a typical acute-care setting, which revenue cycle area uses an internal auditing system (scrubber) to ensure that error free claims (clean claims) are submitted to third-party payers?
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Claims processing
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In a typical acute-care setting, Charge Entry is located in which revenue cycle area?
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Claims processing
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Most facilities begin counting days in accounts receivable at which of the following times?
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The date the bill drops
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Which of the following is NOT a use of the CDM?
*Produce hospital claims *Utilization management *Coder productivity *Monitor resource consumption |
Coder productivity
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The amount of money owed a healthcare facility when claims are pending is called:
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Dollars in accounts receivable
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Which entity is responsible for processing Part A claims and hospital-based Part B claims for institutional services on behalf of Medicare?
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Medicare Administrative Contractor
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What is the definition of revenue cycle management?
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Coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue
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Which of the following is NOT used to reconcile accounts in the patient accounting department?
*Explanation of benefits *Medicare Code Editor *Remittance Advice *Medicare Summary Notice |
Medicare Code Editor
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True/False
In regard to accounts receivable management, the older the account or the longer the account remains unpaid, the less of a chance that the facility will receive reimbursement for the encounter. |
True
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When revenue cycle analysts examine MS-DRG relationships reporting they examine MS-DRG families for differences in ___________ reporting.
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Complication/comorbidity
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What is a characteristic of the "old" RCM approach?
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Silo mentality
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In healthcare settings, the record of the cash the facility will receive for the services it has provided is known as:
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Accounts receivable
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Which of the following compliance documents services as day-to-day operating instructions for administering CMS programs?
*CMS Program Transmittals *National Coverage Determinations *Medicare Claims Processing Manual *National Correct Coding Initiative |
Medicare Claims Processing Manual
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What three components do value-based purchasing (VBP) systems and pay-for-performance (P4P) systems typically link?
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Quality, Performance, and Payment
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What three reports provided the impetus for VBP/P4P systems?
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*To Err Is Human: Building A Safer Health System
*Crossing the Quality Chasm: A New health System for the 21st Century *Rewarding Provider Performance: Aligning Incentives in Medicare |
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True/False
VBP/P4P systems only include financial rewards. |
False
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True/False
VBP/P4P systems have been slow in getting established since 2004. |
False
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What are the two major categories of VBP/P4P models?
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Reward-based models and Penalty-based models
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What targets should be the focus of VBP/P4P systems?
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Most significant problems in terms of quality or cost, proportion of population covered by the service or provider, and availability of valid and reliable performance measures.
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What is the ramification for hospitals that do not participate in, or do not submit sufficient data under, the Hospital IQR program?
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Two percent reduction in the annual payment update
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How did the hospital penalty change under the revised Hospital-Acquired Conditions Reduction Program?
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The penalty changed from a per-encounter reduction to an all-encounter reduction (all encounters in the payment year)
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Which focus areas and conditions are included in the Hospital Re-admissions Reduction Program?
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*2015- heart Failure, Acute Myocardial Infarction, and Pneumonia
*2016-Add Chronic Obstructive Pulmonary Disease (COPD), and Total Hip Arthroplasty, and Total Knee Arthroplasty *2017 - Add Coronary Artery Bypass Graft Surgery |
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What four domains are included in the Hospital Value-Based Purchasing Program?
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*Safety Domain,
*Clinical Care Domain, *Efficiency and cost reduction domain, *Patient experience of care domain |
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How does the Physician Feedback Program/Value-Based Payment Modifier support the move to reimbursing physicians for quality rather than quantity?
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Physicians data is reviewed and shared placed emphasis on quality rather than quantity.
The value modifier (VN) adjusts reimbursement based on the physicians quality and efficiency of care. |
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What three fundamental characteristics do value-based purchasing (VBP) systems and pay-for-performance (P4P) systems share?
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measurement, transparency, and accountability
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Why did VBP/P4P systems emerge?
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to increase quality and safety in healthcare and to control rising cost
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What is attribution, and by what other term is this process known?
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determine who rendered care so that the care's outcomes can be linked to its provider and that provider receives the reward or penalty
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True/False
The very first P4P systems emerged in the early 1990s. |
False
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True/False
The Centers for Medicare and Medicaid Services (CMS) has attempted to slow the trend toward VBP/P4P systems because its experts believe the linkage of quality and rewards jeopardizes the care of patients. |
True
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List at least three other countries that have implemented VBP/P4P systems in their healthcare delivery systems.
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Australia, Canada, United Kingdom
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True/False
Withholding compensation would be considered a penalty-based model of VBP/P4P. |
True
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What piece of legislation mandated that CMS develop a VBP program?
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Deficit Reduction Act of 2005
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Discuss the difference between "Pay for Reporting" and "Paying for Value."
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Pay for reporting measures how a facility gathers data, and puts it in the right format and then submits it by deadline.
Paying for value uses the hospital/provider's quality data to modify payments to the hospital/provider that performed lower than expected. |
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What type of VBP program is the Hospital-Acquired Conditions Reduction Program?
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Paying for value
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Which of the following statements about the Hospital Readmission Reduction Program is false?
*The Affordable Care Act (ACA) established the Hospital Readmission Reduction Program *IPPS MS-DRG payments are reduced by a hospital-specific amount that accounts for the hospital's excessive readmission's *The program collects readmission data for only Medicare patients *Only specified conditions are included in the program for each year |
The program collects readmission data for only Medicare patients
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What is the term that means making available to the pubic, in a reliable and understandable manner, information on a healthcare organization's quality, efficiency, and consumer experience with care, which includes price and quality data, so as to influence the behavior of patients, providers, payers, and others to achieve better outcomes?
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Transparency
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In value-based purchasing and pay-for-performance systems, which incentive is financial?
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Higher fee schedule
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What is the payment reduction for hospital and facilities that fail to successfully meet the requirements of Medicare's Pay for Reporting programs?
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2% reduction
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In value-based purchasing and pay-for-performance systems, which attribute should adopted performance measures characterize?
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Relevant
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What reports drove the establishment of value-based purchasing and pay-for-performance and systems in the healthcare sector?
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*Crossing the Quality Chasm: A New Health System for the 21st Century
*Rewarding Provider Performance: Aligning Incentives in Medicare *To Err is Human: Building a Safer Health System |
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Since the 2000s, what terms characterize the rate of establishing value-based purchasing and pay-for-performance and systems in the healthcare sector?
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Wide-spread implementation
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In the healthcare sector, why are incremental implementations of value-based purchasing and pay-for-performance systems preferable to full-scale implementations?
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Sponsors can evaluate policies and procedures
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Which piece of legislation initiated the Reporting of Hospital Quality Data for Annual Payment Update (RHQDAPU) program?
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Medicare Modernization Act
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What is the term for a model of primary care that seeks to meet the health care needs of patients and to improve patient and staff experiences, outcomes, safety, and system efficiency?
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Patient-centered medical home
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True/False
The Physician Feedback Program/Value-Based Payment Modifier program will include all physicians, regardless of practice size, by 2017. |
True
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Value-based purchasing and pay-for-performance systems typically link all of the following components EXCEPT:
*Quality *Setting of care *Performance *Payment |
Setting of care
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A patient is admitted with pneumonia. 3 days after admission, the patient develops a urinary tract infection secondary to the catheter put in at admission. What will happen to the patient's DRG?
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The UTI from the catheter will not be counted as a CC due to the fact that it was not present on admission
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Which component of Medicare's Value Based Purchasing plan monitors the action of reporting data in the proper format within the given time-frame?
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Pay for Reporting
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True/False
Pay-for-performance and value-based purchasing systems are phenomena unique to the U.S. healthcare delivery system. |
False
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What are the two major categories of pay-for-performance models?
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Reward-based models and penalty-based models
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In the Hospital Value Based Purchasing program a facility's total performance score (TPS) is used to determine the amount of hold-back dollars the facility has earned back. In regard to the TPS which is better?
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A higher TPS is better
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When did pay-for-performance systems first emerge in the healthcare sector?
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1970's
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What targets should be the focus of pay-for-performance and value-based purchasing systems?
*Most significant problems in terms of quality or cost *Proportion of population covered by the service or provider *Availability of valid and reliable performance measure *A and B only *All of the above |
All of the above
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In value-based purchasing and pay-for-performance systems, what is the term for the process of identifying the clinician who provided the care, is responsible for the care's quality and is accountable for the care's cost?
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Attribution
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