Healthcare Accounting Billing & Reimbursement Flashcards

What is the primary function of the Medicare Cost Report (Form CMS-2552) filed by hospitals?

Answer: To reconcile interim payments received throughout the year against actual allowable costs to determine the final settlement amount

The Medicare Cost Report is used to calculate the difference between interim payments made to a hospital during the year and its actual allowable costs, resulting in either a final payment or a refund to CMS.

When a claim is submitted with a Modifier -59, what does the provider attest?

Answer: The procedure represents a distinct procedural service not normally reported together with another code but appropriately billed separately on that day

Modifier -59 is used to indicate that a procedure or service was distinct or independent from other services performed on the same day, overriding a bundling edit when appropriate.

A provider bills Medicare $800 for a service with an allowed amount of $500. The patient has met their deductible. What is Medicare's payment to a non-participating provider who does not accept assignment?

Answer: $380 (80% of 95% of the $500 allowed amount)

Non-participating providers who do not accept assignment are paid 80% of 95% of the Medicare fee schedule (the limiting charge is 115% of 95% of the fee schedule), so Medicare pays the provider at the reduced rate.

Under HIPAA, what is the standard electronic format required for submitting professional claims to Medicare?

Answer: CMS-1500 (837P)

The 837P (Professional) is the HIPAA-mandated electronic transaction format for submitting professional claims, corresponding to the paper CMS-1500 form.

What is the purpose of a 'denial management' program in healthcare revenue cycle operations?

Answer: To systematically track, analyze, appeal, and prevent claim denials to maximize reimbursement

Denial management involves identifying patterns in denied claims, correcting and resubmitting them, filing appeals when appropriate, and implementing front-end process improvements to prevent future denials.

Which of the following scenarios would most likely trigger a Medicare Secondary Payer (MSP) situation, making Medicare the secondary payer?

Answer: A Medicare beneficiary aged 68 who is actively employed and covered under their employer's group health plan with more than 20 employees

When a Medicare beneficiary is actively employed and covered by a group health plan from an employer with 20 or more employees, the employer's plan is primary and Medicare is secondary.

A healthcare organization wants to measure the effectiveness of its billing department. Which metric best reflects the percentage of billed charges actually collected after all adjustments?

Answer: Net collection rate

The net collection rate measures collections as a percentage of net charges (after contractual adjustments), indicating how effectively the organization collects what it is legally entitled to.