CRCR Claims Processing and Reimbursement 3

Question 1

What is the global period in Medicare surgical billing and how does it affect reimbursement?

Accepted Answer

The defined post-operative period during which follow-up care is included in the surgical fee and cannot be billed separately

Answer

The 12-month period before surgery when pre-authorization must be obtained

Answer

The time limit for submitting surgical claims to Medicare

Answer

The period during which Medicare reviews the surgery for medical necessity

Question 2

What does it mean when a claim is pended by a payer?

Accepted Answer

The claim is being held for additional review or information before adjudication can be completed

Answer

The claim has been paid and closed

Answer

The claim was rejected due to missing data

Answer

The claim was assigned to a collection agency

Question 3

What is capitation in managed care reimbursement?

Accepted Answer

A fixed monthly payment per enrolled member that covers all services in a defined scope regardless of utilization

Answer

A fee paid for each service rendered

Answer

A bonus paid to physicians who meet quality benchmarks

Answer

A penalty assessed when a plan's cost exceeds its premium revenue

Question 4

What is a provider-preventable condition in hospital billing?

Accepted Answer

A condition or complication that occurs during the hospital stay that reasonable care could have prevented for which Medicare does not pay additional amounts

Answer

A chronic condition that the hospital is required to treat at no charge

Answer

A condition identified in the patient's medical history before admission

Answer

A complication that qualifies for additional reimbursement under DRG outlier rules

Question 5

How does the Medicare Advantage reimbursement model differ from traditional Medicare fee-for-service?

Accepted Answer

Under Medicare Advantage, private insurers are paid a risk-adjusted capitated rate by CMS to manage benefits for enrolled beneficiaries often using their own provider networks and utilization management tools

Answer

Medicare Advantage pays providers higher rates than traditional Medicare in all cases

Answer

Medicare Advantage uses the same DRGs and fee schedules as traditional Medicare without exception

Answer

Medicare Advantage does not cover hospital inpatient services

Question 6

What is the significance of data benchmarking in revenue cycle performance management?

Accepted Answer

Comparing an organization's KPIs against industry standards or peer organizations to identify performance gaps and opportunities

Answer

Comparing the organization's EHR system to competitor systems

Answer

A process for verifying that data is stored securely

Answer

A federal requirement for all Medicare-participating hospitals