Question | Answer |
PPS | Prospective Payment System. Used to calculate payments for Medicare, Medicaid |
DRG | Diagnostic Related Group. Used to pay hospital admissions based upon a single diagnosis (organ) |
RBRVS | Resource based Relative Value Scale. Used to pay doctors, clinics and hospitals based upon resources required to provide treatment |
RVS | Relative Value Scale. A range of values for procedure payments. Each procedure has a relative weight and payment amount. |
Calculating the RVS | This is based upon the relative weight and payment amount.
A relative weight of .5 and dollar amount of $100 would be calculated as: .5 x 100.00 = 50.00 |
LAN | Local area network. A network that is internal to a hospital, clinic, medical center, etc. |
EHR, EMR | Electronic Health Record, Electronic Medical Record. A computerized collection of personal and medical information of patients. This system also includes the ability to interact with patients and providers via the internet. |
Capitation | A payment method where the doctor is paid a single dollar amount based upon the population of patients in an insurance plan. |
Fee-For-Service | A payment method in which the doctor is paid per procedure. |
Factors considered in DRG payments | Secondary diagnosis, patient age, complications (present or not), comorbidities |
comorbidity | a co-existing disease. Secondary disease. Secondary diagnosis. For example, Gangrene due to Diabetes. |
APC | Ambulatory Payment Classification. A service classification system for outpatient encounters. This can be paid to a hospital only if it is for OUTPATIENT encounters. You have page 5 of this type of list. |
RUGs | Resource Utilization Groups. Payment system. A payment system used for SNF |
The medicare RBRVS is based upon three factors: | Physician's work (procedure) + Practice Expense + Liability |
The PPS systems are "peer reviewed" in order to monitor | Quality of care, appropriate admissions and discharges, appropriateness of outlier cases. |
Outlier | A term in statistics that is used to describe elements that do not fit the norm. In the DRG system for example, this someone with more than one diagnosis upon admission. |
Today's billing software is able to: (list at least 4 items) | IN YO NOTES |
Account aging or Patient Aging | Listing all patients/accounts with a balance unpaid for 30, 60, or 90 days. |
Patient expectations are based upon: | previous experiences, the media, opinions of others |
To be up front with officer policy is to be clear by having policies and accounting information | PRINTED |
Staff members can talk about their crazy patients at lunch as long as no one overhears them. | FALSE. |
A ___________________ is required before information can be released. | Signed "release of information". Signature must be of the patient or the guardian. |
"Covered entities" in HIPAA refers to: | Providers, insurance plans, healthcare clearing houses. |
Clearing houses | Electronic systems that analyze the insurance claim and screen it for errors and missing data. |
PHI | Protected Health Information |
Patients have the right to see and even correct errors in the medical chart | TRUE |
Patients can get copies of their health record from clearing houses | FALSE |
Releasing medical data without identifying the patient is called: | de-identification |
The Truth in Lending act requires: | Clear statement of : the interest charge, when payments are due, any service charges or late payment charges |
Fair Credit Billing Act requires: | Errors be corrected within a specified period of time. |
Equal Credit Opportunity Act | Requires the provider to offer credit to all without discrimination |
Primary diagnosis | Main reason for hospital admission. |
etiology | the cause of a disease |