Revenue Cycle Management & Medical Billing Flashcards

A practice manager is evaluating whether to appeal a denied claim. Which factor is MOST important to assess first?

Answer: Whether the appeal deadline specified in the payer contract has passed

Payer contracts and regulations specify strict appeal timelines; missing the deadline forfeits the right to appeal regardless of the validity of the denial.

Which of the following is an example of upcoding, a fraudulent billing practice?

Answer: Billing for a 99213 when documentation only supports a 99212

Upcoding is billing for a higher-level service than what is documented; billing a 99213 when documentation only supports a 99212 is a classic example.

A medical practice wants to improve patient collections. Which strategy has been shown to be MOST effective?

Answer: Collecting patient responsibility amounts at the time of service

Research consistently shows that collecting patient balances at the point of service dramatically improves collection rates, as the likelihood of payment declines significantly over time.

In value-based payment models, which metric directly measures whether a practice's spending on a patient population aligns with the payer's budget target?

Answer: Per Member Per Month (PMPM) cost

PMPM cost measures total expenditures divided by enrolled members and is the core financial metric in capitation and shared savings contracts.

Which federal program requires providers to submit cost reports annually, and uses those reports to reconcile interim payments made throughout the year?

Answer: Medicare Fee-for-Service (Traditional Medicare)

Traditional (Fee-for-Service) Medicare requires cost reports from institutional providers to reconcile actual costs against interim payments made during the fiscal year.

A practice's accounts receivable aging report shows that 35% of outstanding balances are over 120 days. This level is BEST described as:

Answer: A significant red flag indicating collection process problems

Industry benchmarks suggest no more than 10-15% of A/R should be over 120 days; 35% signals serious breakdowns in follow-up, denial management, or patient collections.

Which of the following best describes the purpose of a remittance advice (RA) in the billing cycle?

Answer: A payer's explanation of how a claim was adjudicated and what was paid or denied

The remittance advice (also called Explanation of Benefits or EOB) is issued by the payer to the provider explaining payment amounts, adjustments, and denial reasons for submitted claims.