I85PREP
⌘ K
PMRP study materials
PMRP study resources

PMRP: Revenue Cycle Fundamentals and Regulatory Compliance

PMRP · Work through your exam, one topic at a time.

All guide sections

Revenue Cycle Fundamentals and Regulatory Compliance

Domain 1: Revenue Cycle Fundamentals and Regulatory Compliance

This domain tests the end-to-end revenue cycle and the laws that constrain it. Expect questions on Medicare Secondary Payer (MSP), the False Claims Act (FCA), Anti-Kickback Statute (AKS), Stark Law, HIPAA, EMTALA, 501(r), the No Surprises Act, and Medicare Advance Beneficiary Notices (ABNs).

Core rules

  • The cycle runs front end (scheduling, eligibility, registration), mid cycle (coding, charge capture, claims), and back end (denials, posting, AR, collections).
  • Medicare is secondary when another payer is primary under MSP; the MSP Questionnaire must be asked and documented.
  • An ABN is required before billing a Medicare beneficiary for items or services expected to be denied as not medically necessary; it is not used for statutorily excluded services, which call for a voluntary notice.
  • 501(r): tax-exempt hospitals must maintain a written financial assistance policy, limit charges to amounts generally billed (AGB), and avoid extraordinary collection actions before screening for assistance.
  • No Surprises Act: protects patients from balance billing for emergency care and certain out-of-network care at in-network facilities; good faith estimates apply to uninsured and self-pay patients.
  • FCA liability attaches to knowingly false claims; AKS prohibits remuneration for referrals; Stark restricts certain physician self-referrals.

Worked example

A 62-year-old with Medicare and active employer coverage through a spouse is registered for an office visit. The registrar marks Medicare primary. The claim denies because the employer plan is primary under MSP working-aged rules. Correct action: complete the MSPQ, bill the employer plan first, then Medicare secondary. The denial is avoidable, and the root cause is registration, not coding.

Traps

Assuming Medicare is always primary; using an ABN for excluded services; referring to collections before 501(r) screening; treating the No Surprises Act as applying to all out-of-network care.