Revenue Cycle Management Flashcards
7 cards from real CMRT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Revenue Cycle Management flashcards as text
When a patient has both Medicare Part A and an employer group health plan, which payer is typically primary?
Answer: The employer group plan is primary if the employer has 20 or more employees
Under Medicare Secondary Payer (MSP) rules, the employer's group plan is primary when the employer has 20+ employees and the patient is an active employee.
What is the function of the National Provider Identifier (NPI) in revenue cycle management?
Answer: It uniquely identifies healthcare providers on all HIPAA standard transactions
The NPI is a unique 10-digit identifier required on all HIPAA electronic transactions to identify the rendering, billing, and referring providers.
A hospital bills Medicare for an inpatient stay. Under which payment system is reimbursement calculated?
Answer: Diagnosis-Related Group (DRG)
Medicare reimburses inpatient hospital stays using the Inpatient Prospective Payment System (IPPS), which assigns a fixed payment based on the patient's DRG.
Which of the following best describes 'balance billing' in a managed care setting?
Answer: Billing the patient for the difference between the provider's charge and the contracted rate
Balance billing occurs when a provider bills the patient for the difference between their charge and the payer-contracted rate, which is prohibited for in-network providers under most contracts.
A coder assigns a higher-level E/M code than is supported by the documentation. This is an example of:
Answer: Upcoding
Upcoding means assigning a billing code that reflects a higher level of service than what was actually documented or performed.
What is the purpose of an Advance Beneficiary Notice (ABN) in Medicare billing?
Answer: To inform a Medicare beneficiary that a service may not be covered and they may be responsible for payment
An ABN is given to Medicare beneficiaries before providing a service that may not be deemed medically necessary, so they can decide whether to proceed knowing they may owe the cost.
Which internal control best reduces the risk of duplicate claim payments in the revenue cycle?
Answer: Implementing claim scrubbing software that flags duplicate submissions
Claim scrubbing software identifies duplicate claims before submission, preventing overpayment requests and payer-side denials.