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jfrane
Health Insurance
| Question | Answer |
|---|---|
| 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
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