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Health Insurance

Rates established in advanced but based on reported health care costs (charges) from which a predetermined per diem rate is determined Prospective cost-based rates
Rates associated with a particular category of patient(inpatient) and established by the payer prior to the provision of health care services. Prospective price-based rates
any patient with a diagnosis from 1 of 10 CMS determined DRG's who is discharged to a post acute provider, is treated as a transfer case: this means hospitals are paid a graduated per diem rate for each day IPPS (inpatient prospective payment system) transfer rule
Payment system that reimburses providers for services and procedure by classifying services according to RVU's MPFS-Medicare physician fee schedual
issues predetermined payment for services PPS-Prospective payment system
Payment system for ambulance service for Medicare beneficiaries Ambulance fee schedule
Medicare has reimbursed hospitals for inpatient hospital services according to a predetermined rate for each discharge IPPS-inpatient prospective payment system
Medicare reimburses DMEPOS either 80% of the actual charge for the item or the fee schedule amt. whichever is less DMEPOS-durable medical equipment, prosthetics/orthotics, and suplies fee schedule
What bundles ESRD drugs and related lab tests with the composite rate payment,resulting in one reimbursement amount paid for ESRD services provided to patients? ESRD composite payment rate system
uses a classification system called home health resource group to establish prospective reimbursement rates for 60 day episode of home health care HH PPS- home health prospective payment system
data entry software is then used to collect OASIS assessment data for transmission to state database HAVEN-home assessment validation and entry
Medicare payments for hospital inpatient care were based on a ------ which meant hospitals received 80% of reasonable charges retrospective reasonable cost system
Extent of physiological decompensation or organ system loss of function SOI-severity of illness
Likelyhood of dying ROM-risk of mortality
Centers of Medicare and Medicaid Services formerly HCFA CMS
third-party payer that contracts Medicare to carry out the operational functions of the Medicare program MAC-Medicare administrative contractor
uses ambulatory payment classification (APC) to calculate reimbursement: was implemented for billing of hospital-based Medicare outpatient claims OPPS -Outpatient Prospective Payment System
Adjusts payments to account for geographic variations in hospitals labor costs wage index
Software is the computerized data entry system used by inpatient rehab facilities to creat a file in a standard format IRVEN- Inpatient Rehabilitation Validation and Entry
LTCHPPS- Long-term(acute) care hospital Prospective Payment System This prospective system replaces the reasonable cost-based pmt. system under which long-term (acute)care were previously paid
SNF PPS-Skilled Nursing Facility Prospective Payment System SNF's were no longer paid on a reasonable cost basis but rather on the basis of PPS
Data entry system used to enter MDS data about SNF patients and transmit those assessments to individual state databases RAVEN- Resident Assessment Validation and Entry
reimburses providers according to predetermined rates assigned to services (revised every year) MPFS-Medicare Physician Fee Schedule
dollar multiplier that converts relative value units (RVU's) into payments conversion factor
Does not accept assignment from Medicare-subject to a 5% reduction of Medicare Physician fee schedule(MPFS) non-PAR- nonparticipating provider
[MPFS-(MPFSx5%)]x115%=MPFS-Medicare Physician fee schedule limiting charge
Notifies Medicare Beneficiaries of actions taken on claims MSN- Medicare Summary Notice
MSP- Medicare Secondary Payer ie.auto ins, workers comp, EGHP (employer group health plan)
Created by: jfrane