CMSM CMSM Healthcare Finance and Revenue Cycle Management 2 — Questions and Answers
Question 1: A CMSM is reviewing the facility's payer mix. Which payer type generally reimburses providers at the highest rate?
- Medicaid
- Medicare
- Commercial insurance (Correct answer)
- Self-pay patients
Correct answer: Commercial insurance
Commercial (private) insurance typically reimburses providers at higher rates than government payers such as Medicare or Medicaid.
Question 2: What is the primary purpose of a charge description master (CDM) in a healthcare facility?
- To list all registered patients
- To standardize and maintain billable service codes and prices (Correct answer)
- To track staff scheduling costs
- To document physician credentialing
Correct answer: To standardize and maintain billable service codes and prices
The CDM (also called the chargemaster) is a comprehensive list of all billable items, including service codes, descriptions, and standard charges used for billing.
Question 3: Under the No Surprises Act (effective 2022), what must providers do before delivering non-emergency care to self-pay or uninsured patients?
- Collect full payment upfront
- Provide a Good Faith Estimate of expected charges (Correct answer)
- Obtain a referral from a primary care physician
- Submit a prior authorization to CMS
Correct answer: Provide a Good Faith Estimate of expected charges
The No Surprises Act requires providers to give self-pay and uninsured patients a Good Faith Estimate of anticipated costs before scheduling or providing non-emergency services.
Question 4: Which financial metric represents the percentage of billed charges actually collected by a healthcare facility?
- Gross collection rate
- Net collection rate (Correct answer)
- Denial rate
- Clean claim rate
Correct answer: Net collection rate
The net collection rate measures actual collections against the net amount expected after contractual adjustments, reflecting true revenue cycle efficiency.
Question 5: A medical services manager wants to reduce claim denials related to medical necessity. Which action is most effective?
- Increase front-desk staffing
- Implement prospective utilization review before services are rendered (Correct answer)
- Switch to a paper-based billing system
- Reduce the number of payer contracts
Correct answer: Implement prospective utilization review before services are rendered
Prospective utilization review evaluates the medical necessity of services before they are provided, preventing denials that occur when payers determine a service was not medically justified.
Question 6: Which of the following best describes a capitation payment model?
- A per-service fee paid after each visit
- A fixed monthly fee paid per enrolled patient regardless of services used (Correct answer)
- A bundled payment for a single episode of care
- A cost-plus reimbursement arrangement
Correct answer: A fixed monthly fee paid per enrolled patient regardless of services used
Capitation pays providers a set monthly amount per covered patient, incentivizing preventive care since the provider assumes financial risk for utilization.
CMSM CMSM Healthcare Finance and Revenue Cycle Management 2
A CMSM is reviewing the facility's payer mix.
Which payer type generally reimburses providers at the highest rate?