CHAA Revenue Cycle Management Flashcards
6 cards from real CHAA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CHAA Revenue Cycle Management flashcards as text
What is 'prospective payment' in healthcare?
Answer: A payment system where the reimbursement amount is determined before services are rendered based on predetermined rates
Prospective payment is a reimbursement method where the payment amount is established before services are rendered, typically based on the patient's condition or procedure. The DRG system for hospital inpatients is the most common example. This contrasts with retrospective payment, where charges are determined after services are provided.
What is the significance of the '270/271' transaction in eligibility verification?
Answer: The 270 is an electronic eligibility inquiry and the 271 is the eligibility response from the payer
The 270 transaction is the HIPAA-standard electronic format for submitting eligibility inquiries to insurance companies, and the 271 is the standard response format containing the patient's coverage information. This electronic exchange enables real-time eligibility verification at the point of registration. Automating 270/271 transactions significantly improves front-end efficiency.
What is 'capitation' as a payment model?
Answer: A fixed per-member per-month payment regardless of services provided
Capitation is a payment model in which a provider receives a fixed, predetermined amount per enrolled member per month, regardless of whether the patient seeks care or how many services are provided. This shifts financial risk from the payer to the provider and incentivizes preventive care and efficiency. It is common in managed care arrangements.
What is 'claims reconciliation'?
Answer: Comparing submitted claims against payments received to ensure accuracy and identify discrepancies
Claims reconciliation involves comparing submitted claims against the payments and adjustments received to verify that reimbursement is accurate and complete. This process identifies discrepancies such as underpayments, overpayments, and unresolved denials. Regular reconciliation ensures financial accuracy and identifies trends that need attention.
How does a high deductible health plan (HDHP) affect the revenue cycle?
Answer: It increases patient financial responsibility and the importance of upfront collections and financial counseling
High deductible health plans shift more financial responsibility to patients, increasing the importance of verifying deductible status, providing cost estimates, collecting at the point of service, and offering payment plans. As HDHPs have become more common, self-pay after insurance has become one of the largest sources of accounts receivable for many providers.
What is 'charge reconciliation' in the revenue cycle?
Answer: Comparing charges entered in the billing system against clinical documentation to ensure completeness
Charge reconciliation is the process of comparing the charges captured in the billing system against the clinical documentation and departmental logs to ensure that all services provided have been accurately recorded and billed. This prevents revenue leakage from missed charges and ensures billing accuracy.