Mixed Deck — All CRCR Topics Flashcards

Which key performance indicator (KPI) measures the percentage of claims that are accepted and paid on the first submission without requiring rework?

Answer: First-pass resolution rate (FPRR)

The first-pass resolution rate (FPRR) tracks the percentage of claims adjudicated correctly on initial submission, reflecting billing accuracy.

What is the primary goal of a charity care screening conducted during patient access?

Answer: To identify patients who may qualify for free or reduced-cost care based on financial need

Charity care screening during registration identifies financially disadvantaged patients early so appropriate assistance can be arranged before or after service.

A payer requires a referral from the patient's primary care physician (PCP) before covering a specialist visit. This requirement is characteristic of which plan type?

Answer: Health Maintenance Organization (HMO)

HMO plans typically require members to select a PCP and obtain referrals for specialist services; PPOs and indemnity plans generally do not have this requirement.

When a patient's insurance card shows a $200 deductible with $150 already met, how much should be collected at point of service for a $300 visit?

Answer: $50 remaining deductible only

Only the remaining deductible balance of $50 ($200 - $150 already met) should be collected at the time of service.

When a payer requests 'peer-to-peer' review after denying a prior authorization, what does this process involve?

Answer: The treating physician speaking directly with the payer's medical director to present clinical justification for the requested service

A peer-to-peer review is a direct physician-to-physician conversation between the treating provider and the payer's medical director, giving the clinician an opportunity to advocate for medical necessity before a formal appeal is filed.

What is the role of Clinical Documentation Improvement (CDI) specialists in charge capture?

Answer: They concurrently review records and query physicians to ensure diagnoses and procedures are fully documented to support accurate coding and reimbursement

CDI specialists bridge the gap between clinical documentation and coding by identifying documentation gaps and querying providers to ensure complete, accurate, and specific records.

A self-pay patient presents for a non-emergent service. What is the most appropriate financial counseling approach?

Answer: Discuss charity care, payment plans, and any available financial assistance programs

Financial counselors should proactively discuss all available options including charity care and payment plans to help self-pay patients access needed care.

When filing an appeal for a denied claim, what must typically be included to maximize the chance of overturn?

Answer: A cover letter, the denial explanation, supporting clinical documentation, and any relevant payer policy

A well-supported appeal package includes a cover letter explaining the basis for the appeal, clinical documentation, and references to payer policies or guidelines.

What is the consequence of billing a service that required prior authorization but for which authorization was not obtained?

Answer: The claim will typically be denied and the provider may be responsible for writing off the balance

Most payers require prior authorization for specific services and failure to obtain it results in a claim denial that the provider generally cannot bill to the patient.

What is natural language processing and how is it used in clinical documentation improvement?

Answer: AI technology that reads and analyzes unstructured clinical text to identify documentation gaps, suggest more specific diagnoses, or flag missing codes

NLP enables automated analysis of clinical notes to identify opportunities to improve documentation specificity and capture more accurate and complete codes.

Which type of HCPCS Level II code is primarily used to report durable medical equipment (DME)?

Answer: E codes

HCPCS Level II 'E' codes are specifically designated for durable medical equipment, orthotics, and prosthetics.

What does the term 'coordination of benefits' (COB) mean in revenue cycle compliance?

Answer: The process of determining which payer is primary and which is secondary when a patient has multiple insurance coverages

COB is the standardized process for determining the order in which multiple insurers pay claims to prevent total payment from exceeding 100% of the actual charges.

A patient presents to the ED and the physician documents a high-complexity medical decision making with greater than 60 minutes of total time. Which E/M level is most appropriate?

Answer: 99285

99285 represents the highest standard ED E/M level, requiring high-complexity MDM or 60+ minutes of time.

A patient arrives for an elective procedure but did not complete the required pre-authorization. What should the patient access team do?

Answer: Attempt to obtain authorization before the procedure begins or notify the physician

Attempting to secure authorization prior to service or escalating to the physician prevents a potential denial, as retro-authorization is not guaranteed and often denied by payers.

A claim denied for 'lack of prior authorization' is later discovered to have had authorization obtained but the wrong auth number was entered. What is the best resolution path?

Answer: File an appeal with proof of the valid authorization number and confirmation from the payer

Submitting an appeal that includes documented proof of the valid prior authorization demonstrates that authorization was secured and the denial was due to a data entry error.

Which of the following is a key benefit of collecting patient balances at the point of service rather than post-service?

Answer: It significantly reduces bad debt and cost-to-collect

POS collections dramatically reduce bad debt because the probability of collecting a balance drops significantly after the patient leaves the facility, and post-service collection is far more expensive.

On the CMS-1500 form, Box 21 is used to report which of the following?

Answer: Diagnosis codes in ICD format

Box 21 on the CMS-1500 is designated for up to 12 ICD-10-CM diagnosis codes that support medical necessity for the services billed.

A hospital's compliance program discovers a billing error that resulted in overpayment from Medicare. Under the 60-day rule, when must the overpayment be reported and returned?

Answer: Within 60 days of identification or the date of a corresponding cost report, whichever is later

The ACA's 60-day rule requires that identified Medicare/Medicaid overpayments be reported and returned within 60 days of identification, or the overpayment becomes a false claim.

What is the difference between a data warehouse and an operational revenue cycle system?

Answer: Operational systems support day-to-day transaction processing; data warehouses consolidate historical data from multiple systems for analysis and reporting

Operational systems handle real-time transactions while data warehouses aggregate historical data from multiple sources for analytics.

A patient with a large outstanding balance informs the collections specialist that they recently lost their job and cannot pay. What is the MOST appropriate initial action for the specialist to take?

Answer: Screen the patient for eligibility under the hospital's financial assistance policy.

The most appropriate and patient-centric first step is to determine if the patient qualifies for financial assistance or charity care. Hospitals are required to have financial assistance policies, and this approach helps differentiate between an unwillingness to pay (bad debt) and an inability to pay (charity care).