Revenue Cycle Management Flashcards

A hospital has a gross charge of $10,000, a contractual adjustment of $4,000, and collected $5,500. What is the net collection rate?

Answer: 91.7%

Net collection rate = Collections / (Gross Charges − Contractual Adjustments) = $5,500 / $6,000 = 91.7%.

What is 'prior authorization' in the context of revenue cycle management?

Answer: Approval obtained from the payer before delivering certain services

Prior authorization is payer approval secured before rendering specific services to confirm coverage and medical necessity.

Which billing form is primarily used by hospitals and facility-based providers to submit claims to Medicare and Medicaid?

Answer: UB-04 (CMS-1450)

The UB-04 (CMS-1450) is the standard institutional claim form used by hospitals, skilled nursing facilities, and other facility providers.

What does 'timely filing' refer to in revenue cycle management?

Answer: Submitting claims to payers within the contractually or legally required time frame

Timely filing deadlines are set by payers; claims submitted after the deadline are typically denied with no right to appeal.

In value-based reimbursement models, providers are primarily rewarded for:

Answer: Achieving quality outcomes and cost efficiency

Value-based care reimbursement ties payment to quality metrics, patient outcomes, and cost containment rather than service volume.

Which of the following is an example of a 'soft denial' in healthcare claims management?

Answer: A request for additional clinical documentation that can be resubmitted

Soft denials are temporary and can be resolved by submitting additional information; they are not permanent payment refusals.

What is 'charge capture' in the revenue cycle process?

Answer: The process of recording all services, supplies, and procedures provided to a patient for billing purposes

Charge capture is the process of documenting every billable service delivered so that all rendered services can be billed accurately.