CRCR CRCR - Certified Revenue Cycle Representative Program Revenue Cycle Management Fundamentals Questions and Answers 5

Question 1

What is the difference between a write-off and a contractual adjustment in healthcare billing?

Accepted Answer

A contractual adjustment is a pre-negotiated discount per payer contract; a write-off is a balance deemed uncollectable

Answer

Contractual adjustments represent the difference between billed charges and the payer's allowed amount per contract, while write-offs reflect amounts determined to be uncollectable after collection efforts.

Question 2

Under HIPAA, what is the standard electronic transaction for submitting a professional claim to a payer?

Accepted Answer

837P

Answer

The 837P (Professional) transaction is the HIPAA-mandated standard electronic format for submitting professional claims from physicians and other non-institutional providers.

Question 3

Which of the following best describes the purpose of prior authorization in the revenue cycle?

Accepted Answer

To obtain payer approval before certain services are rendered to ensure coverage and payment

Answer

Prior authorization is a payer requirement where providers must obtain approval before delivering specific services, ensuring the payer deems the service medically necessary and covered.

Question 4

What does the term 'upcoding' refer to in healthcare billing compliance?

Accepted Answer

Reporting a higher-level or more complex service than was actually provided to obtain greater reimbursement

Answer

Upcoding is a fraudulent billing practice where providers intentionally report a code for a more expensive service than was performed, which violates the False Claims Act.

Question 5

In managed care contracting, what is a 'carve-out'?

Accepted Answer

A specific service or benefit excluded from a managed care contract and reimbursed under separate terms

Answer

A carve-out separates certain services (e.g., mental health, pharmacy, or lab) from the main managed care arrangement, often reimbursing them under a different fee schedule or through a separate specialty vendor.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR CRCR - Certified Revenue Cycle Representative Program Revenue Cycle Management Fundamentals Questions and Answers 5