Revenue Cycle Management Flashcards

What does 'case mix index' (CMI) measure in a hospital's revenue cycle?

Answer: The relative resource intensity and complexity of the patient population treated

CMI reflects the average DRG weight of all inpatient cases and is used to gauge complexity and resource consumption, directly affecting Medicare reimbursement.

Which of the following is a function of a hospital's Patient Access department in the revenue cycle?

Answer: Registering patients, verifying insurance, and collecting co-pays at point of service

Patient Access is the front-end RCM function responsible for scheduling, registration, insurance verification, and upfront collections.

A provider receives an Explanation of Benefits showing CO-45 as the adjustment reason code. What does this indicate?

Answer: The charge exceeds the fee schedule or maximum allowable amount

CARC CO-45 indicates that the provider's charge exceeds the payer's contracted or allowed fee schedule amount.

What is the 'two-midnight rule' in Medicare inpatient billing?

Answer: A patient is expected to need hospital care spanning at least two midnights to qualify for inpatient admission

Medicare's two-midnight rule states that inpatient admission is appropriate when a physician expects the patient to require care crossing at least two midnights.

In healthcare revenue cycle management, what is 'undercoding'?

Answer: Assigning a lower-level code than what is supported by documentation, resulting in lost revenue

Undercoding means billing a less complex or lower-paying code than the documentation supports, resulting in reimbursement below what was earned.

What is the significance of the 'coordination of benefits' (COB) process in revenue cycle management?

Answer: It establishes which payer is primary and which is secondary when a patient has multiple insurance plans

COB rules determine the order in which multiple payers pay, preventing duplicate payment and ensuring correct billing sequencing.

Which of the following best describes a 'write-off' in healthcare accounts receivable management?

Answer: The removal of an uncollectible balance from accounts receivable after collection efforts are exhausted

A write-off removes a balance deemed uncollectible from AR, typically after collection processes have been completed without recovery.