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Reimbursement Final

Principals of HC Reimbursement AHIMA

QuestionAnswer
In the US, what is healthcare insurance? Reduction of a person's or a group's exposure to risk for unknown healthcare costs by the assumption of that risk by an entity
The physician's office sent a request for payment to Able Insurance. The term used in the HC industry for this request for payment is a(n): Claim
In which type of reimbursement methodology, do HC insurance companies reimburse providers after the costs have been incurred? Retrospective payment
In the HC industry, what is the term for receiving compensation for HC services? Reimbursement
To which of the following factors in health insurance status most closely linked? Employment
In which type of HC payment method does the HC plan pay for each service that a provider renders? Fee-for-service reimbursement
In the HC industry, what is another term for "charge"? Fee
In the accounting system of the physician office, the account is categorized as "self pay". How should the insurance analyst interpret this category? The guarantor will pay the entire bill
What is the term for a predetermined list of charges? Fee schedule
In which type of HC payment method does the HC plan recompense providers with a fixed rate for each day a covered member is hospitalized? Per diem
The coding system that is used primarily for reporting Dx for hospital inpatients is known as: ICD-9-CM
Which coding system was created for reporting procedures and services performed by physicians in clinical practice? CPT
Under MS-DRGs, all of the following factors influence a facility's case mix index except for: The productivity standard for coders
Which of the following is NOT a reason to perform case mix analysis? Determine the correct MS-DRG assignment for an encounter
The practice of under coding can affect a hospital's MS-DRG case mix in which of the following ways? Makes it lower than warranted by the actual service/resource intensity of the facility
Which of the following is the correct format for HCPCS Level II codes? A1234
Which govt. fraud/abuse effort focused on recouping lost funds for Medicare due to inaccurate coding/billing & recovered $188 Mil. in first 2 years? Operation Restore Trust
The 6th scope of Work for QIO introduced which of the following? Payment Error Prevention Program
The policies and procedures section of coding compliance plan should include: Physician query process, unbundling, assignment of discharge destination codes
MS-DRG relationships comparing with CC to without CC DRGs for the same clinical condition should be reviewed because: CCs can be over-coded by coders and CCs can be under-coded by coders
All of the following entities are voluntary insurance except: Medicare
Which of the following entities is also known as a group plan? Employer based HC insurance plan
Which of the following characteristics is the greatest advantage of group health care insurance? Greater benefits for lower premiums
In regards to healthcare insurance the percentage that the guarantor pays is called the...? Coinsurance
Which of the following services has the highest likelihood of being a covered service? Medically necessary
What is the term for the contract between the HC insurance company and the individual or group for whom the company is assuming the risk? Policy
Which part of the medicare program was created under the medicare modernization act of 2003? Part D
This program formerly CHAMPUS Provides coverage for the dependents of active members of the armed forces: Tricare
Which government sponsored programs replaced the aid to families with dependent children AFDC program in 1996? Temporary assistance for needy families program TANF
Which of the following is not a function of the indian health service IHS? Provides only inpatient healthcare services
The civilian health medical program of the department of veterans affairs CHAMPVA is available for: spouse or widow of a veteran meeting specific criteria and children of a veteran meeting specific criteria
which of the following is/are true of SCHIP? Is a federal/state program and varies from state to state
The medicare program is divided into how many parts? 4
Medicare part c is a ______ option known as medicare advantage: managed care
All of the following are true of state medical programs except: services offered to beneficiaries are the same in each state
Which TRICARE Program offers services to active duty family members (ADFMs) With no enrollment, deductible, or copayment fees for covered services? TRICARE Prime
All of the following are characteristics of managed care organizations except: Freedom of choice and autonomous decision making
Access to mental or behavioral health medical specialists is through referral. What is the term for the person who makes the referral? PCP, gatekeeper, primary care provider (all of these)
What is the term that means the evaluating, for a healthcare service, the appropriateness of its setting and it's level of service? Utilization review
Which of the following services is most likely to be considered medically necessary? Standard of care for health condition
All of the following sets represent criteria for medical necessity and utilization review except: Federal Register Index and Ratings
All of the following services are typically reviewed for medical necessity and utilization except: Well-baby check
Gatekeepers determine the appropriateness of all of the following components except: Rate of capitation or reimbursement
The patient belonged to a managed care plan. Prior approval for the surgery was received. What number should the insurance analyst record? Precertification
The patient belonged to a managed care plan. The patient had an elective surgery. Prior approval for it had not been obtained. What should the patient expect? Denial of reimbursement for the surgery
What is the term for an MCO that serves Medicare beneficiaries? Medicare Advantage
In the 1970s, how did factors affect the Medicare Program? The increase in Medicare expenditures for inpatient hospital care jeopardized Medicare's ability to fund other health programs.
Which of the following points is a guideline for the acute hospital prosective payment system? Incentive for cost control because hospitals retain profits or suffer losses based on differences between payment rate and actual costs
What is the average of the sum of the relative weights of all patients treated during a specified time period? Case mix index
The MS-DRG payment includes reimbursement for all of the following inpatient services except: Progress notes
What is the general term for software that assigns inpatient diagnosis related groups? Grouper
What is Medicare's term for a facility with a high percentage of low income patients? Disproportionate share hospital
In MS-DRGs, for what is the case mix index a proxy? Consumption of resources
In the IPPS, what is the term for each hospital's unique standardized amount based on its costs per Medicare discharge? Base payment rate
Which of the following is not a patient level adjustment used in the IPF PPS? Full service emergency department
Medicare inpatient reimbursement levels are based on _____ MS-DRG calculated for the encounter
Which of the following sites is considered a facility in the RBRVS payment system? Ambulance
Which of the following statements is true about APCs? d. APCs are based on the CPT or HCPCS code(s) reported.
the APC system, an outlier payment is paid when which of the following occurs? The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount
The prospective payment system used by hospitals for the majority of services provided to Medicare hospital outpatients is called ______ and became effective on ______. Ambulatory Payment Classifications August 1, 2000
This PPS has been adopted for use by many third party payers (that is, Medicaid) for reimbursement of outpatient visits. It is not the methodology used by Medicare. APGs (Ambulatory Patient Groups)
Under the Ambulance Fee Schedule, the _______________ is used to determine the level of service for ground transport. EMS provider skill set used during the transport
When a patient is pronounced dead prior to an ambulance being called, which of the following payment provisions is followed under the Ambulance Fee Schedule? no payment is made to the ambulance supplier/provider
Under the ASC List multiple procedures performed during the same surgical session are reimbursed at which of the following rate? The procedure in the highest level group receives full payment and the remaining receive half (50%) payment
The Medicare Modernization Act of 2003 mandated the creation of a new PPS for ASC services because ___________________. There is disparity between ambulatory surgical center and hospital outpatient facility payments for the same services
Medicare-certified ASCs must accept assignment, meaning an ASC must accept Medicare payment as payment in full
In which of the PAC payment systems, is the unit of payment the 60-day episode of care? Home health agency
Generally, what is the average length of stay of long-term care hospitals? ≥ 25 days
Patients with all the following conditions are appropriate for LTCHs except: Acute myocardial infarction
In terms of grouping and reimbursement, how are the MS-LTC-DRGs and acute care MS-DRGs similar? Based on principal diagnosis
All of the following elements are part of the IRF PPS except: Major diagnostic category
All of the following types of diagnoses are used in the IRF PPS except: Principal
In the IRF PPS, what is the tool for data collection that drives payment? Patient Assessment Instrument
All of the following services are consolidated into a single payment under the HHPPS except: Durable medical equipment
In which of the PAC payment systems, is the adjusted rate multiplied by the patient’s number of Medicare days to determine the reimbursement amount? Long term care hospital
What is the term used in a rehabilitation facility to mean “a patient’s ability to perform activities of daily living”? functional status
Which of the following is the definition of revenue cycle management? Coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue
The term “hard coding” refers to: CPT codes that appear in the hospital’s charge master
In healthcare settings, the record of the cash the facility will receive for the services it has provided is known as which of the following terms? Accounts receivable
Aging of accounts is the practice of counting the days, generally in ____ increments, from the time a bill has been sent to the payer to the current day. 30-day
Most facilities begin counting days in accounts receivable at which of the following times The date the bill drops
The difference between what is charged and what is paid is known as: Contractual allowance
of the following is not a function area of the revenue cycle? Volunteer services
Which entity is responsible for processing Part A claims and hospital-based Part B claims for institutional services on behalf of Medicare? Fiscal Intermediary
Which of the following is not used to reconcile accounts in the patient accounting department? Medicare Code Editor
What targets should be the focus of pay-for-performance or value-based purchasing systems? for which valid and reliable performance measures are available
Which of the following situations would be included in a penalty-based model of pay-for- performance? Compensation withheld for lack of improvement
Which of the following entities sponsor value-based purchasing or pay-for-performance systems? CMS, Employers, Health Plans. All of the above
How do organizations control costs indirectly Reduce errors
Why are incremental implementations of pay-for-performance systems preferable to full-scale implementations? Sponsors can evaluate policies and procedures
In value-based purchasing and pay-for-performance systems, characteristics of adopted performance measures should include all the following except: Authoritarian
Which of the following incentives is non-financial? Public report cards
In order for P4P and VBP systems to function properly, the system must be able to identify the clinician who provided the care and is responsible for the care’s quality. In P4P and VBP, this process is known as: Attribution
The Tax Relief and Health Care Act of 2006 (MIEA-TEHCA) expanded CMS quality initiatives to which two setting? Hospital outpatient departments and Ambulatory Surgical Centers
Which condition is not included on the Hospital Acquired Conditions provision list for FY 2009? Staphylococcus infections
Which piece of legislation initiated the reporting of the RHQDAPU program? Medicare Modernization Act
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