Healthcare Reimbursement Final Study Guide

In which type of reimbursement methodology does the health insurance company have the greatest degree of risk?

a. Capitated payment
b. Global payment
c. Block grant
d. Retrospective

d. Retrospective

In the healthcare industry, what is another term for "fee"?

a. Capitated rate
b. Charge
c. Discount
d. Reimbursement

b. Charge

In the United States, what is healthcare insurance?

a. Federal program to provide medical care and services to indigent US citizens
b. State programs to provide medical care and services to deserving individuals
c. 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
d. Set of negotiated guarantees that all healthcare expenses of a risk pool will be covered by employers

c. 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

All of the following phenomena are considered "life events" except:

a. Birth
b. Marriage
c. Adoption of a child
d. Illness

d. Illness

To which of the following factors is health insurance status most closely linked?

a. Access
b. Employment
c. Gender
d. Need

b. Employment

Which of the following coding systems was created for reporting procedures and services performed by physicians in clinical practice?

a. ICD-9-CM
b. CPT
c. ICD-10-PCS
d. HCPCS Level II

b. CPT

In the healthcare sector, what is the term for a group of individual entities, such as individual persons, employers, or associations, whose healthcare costs are combined for evaluating financial history and estimating future costs?

a. Limitation
b. Risk pool
c. In-network
d. Wrap-around

b. Risk pool

An annual amount of money that the policyholder must incur (and pay) before the health insurance will assume liability for the remaining charges or covered expenses is known as a _____________

deductible

Explain Risk Pools, how they work and what are the pros and cons.

Group of individual entities, such as individual persons, employers, or associations, whose healthcare costs are combined for evaluating financial history and estimating future costs. Large-employer pools: Employees of one employer, typically 1,000 members or more. Large and diverse. Multiple-employer pools: Employees from several midsize employers or small employers or groups of association. Smaller and less diverse than the large-employer pool. Individual Pools: Self-employed people or people who work for companies that do not offer healthcare insurance. Least diverse because people tend to be similar.

The coding system that is used primarily for reporting diagnoses for hospital inpatients is known as:

a. ICD-10-CM
b. CPT
c. ICD-10-PCS
d. HCPCS Level II

a. ICD-10-CM

Which type of healthcare insurance policy provides benefits to a resident requiring nursing home care and services?

a. Long-term or extended care insurance
b. Accidental death and dismemberment insurance
c. Disability income protection insurance
d. Major medical
e. Medigap

a. Long-term or extended care insurance

What is an Explanation of Benefits (EOB)?

Report sent from a healthcare insurer to the policyholder and to the provider that describes the healthcare service, its costs, applicable cost sharing, and the amount the healthcare insurer will cover. The remainder is the policyholder's responsibility.

What healthcare organization is one of the most influential in the healthcare sector because it insures nearly one in three Americans?

a. Blue Cross Blue Shield
b. Center of Excellence
c. Title 1
d. American Hospital Association

a. Blue Cross Blue Shield

All of the following specifications are types of limitations on healthcare policies except:

a. Benefit cap
b. Cost-sharing provision
c. Geographic plan
d. Use of formulary

c. Geographic plan

A covered service for which the health care company will pay is known as a___________

Benefit

In the healthcare industry, what is the term for receiving compensation for healthcare services that were previously provided?

a. Fee schedule
b. Recompense
c. Reimbursement
d. Render

c. Reimbursement

Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to calculate the group's premiums?

a. To increase premium payments for insurance plan payers
b. To simplify accounting for the group's plan
c. To assure that the pool is large enough to pay losses of the entire group
d. A and B only
e. All of the above

c. To assure that the pool is large enough to pay losses of the entire group

Where did health insurance become established in the United States?

Texas; 1929

The federal role in the healthcare sector is limited to paying providers for the healthcare costs of senior citizens.

a. True
b. False

b. False

What is the purpose of managed care?

To reduce the cost of healthcare services and to improve the quality of care for patients.

The constant trend of increased national spending on healthcare is a concern because as spending on healthcare increases, the money available for other sectors of the economy decreases.

a. True
b. False

a. True

In the accounting system of the physician office, the account is categorized as "self-pay." How should the insurance analyst interpret this category?

a. The employer's self-insured healthcare insurance plan will cover the account.
b. The physician, himself or herself, will pick up the balance of the bill.
c. The guarantor will pay the entire bill.
d. The patient will pay deductibles and non-covered charges.

c. The guarantor will pay the entire bill.

In the healthcare insurance sector, what does UCR stand for?

a. Uniform Crime Report
b. Usual Customary and Reasonable
c. Universal and Common Rates
d. Usable Capital Receipts

b. Usual Customary and Reasonable

In which type of reimbursement methodology do healthcare insurance companies determine payment to providers before the services have been delivered?

a. Block grant
b. Global payment
c. Prospective payment
d. Retrospective payment

c. Prospective payment

There are 3 parties in healthcare reimbursement. Who is the first party?

a. Patient or guarantor
b. Provider of care or services
c. Payer
d. Society

a. Patient or guarantor

There are 3 parties in healthcare reimbursement. Who is the second party?

a. Patient or guarantor
b. Provider of care or services
c. Payer
d. Society

b. Provider of care or services

There are 3 parties in healthcare reimbursement. Who is the third party?

a. Patient or guarantor
b. Provider of care or services
c. Payer
d. Society

c. Payer

Which national model for the delivery of healthcare services is financed by general revenue funds from taxes?

a. Social insurance (Bismarck) model
b. National health service (Beveridge) model
c. Private health insurance model
d. A and B only
e. All of the above

b. National health service (Beveridge) model

Which type of reimbursement methodology is associated with the abbreviation "PMPM"?

a. Capitated payment
b. Global payment
c. Block grant
d. Retrospective

a. Capitated payment

All of the following are efforts to fight healthcare fraud and abuse except:

a. Operation Restore Trust
b. Medicare Integrity Program
c. Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
d. Medicare and Medicaid Patient and Program Protection Act of 1987

c. Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

Common forms of fraud and abuse include all of the following except:

a. Upcoding
b. Unbundling
c. Refiling claims after denials
d. Billing for services not furnished to patients

c. Refiling claims after denials

When people purchase healthcare insurance for themselves and their dependents, they are purchasing single coverage. True or false?

a. True
b. False

b. False

In terms of healthcare insurance coverage, both children and spouses may be considered dependents.

a. True
b. False

a. True

What organization is one of the most influential in the healthcare sector?

Blue Cross Blue Shield

The female worker was just married on July 1, 2016. She had worked for the organization for the past 8 years and has been covered under its group healthcare insurance policy during the entire period. She is ONLY allowed to add her new spouse during open enrollment which, for this organization, is October 1, 2016 through November 1, 2016 becoming effective on January 1, 2017.

a. True
b. False

b. False

All of the following are cost-sharing provisions except:

a. Benefit
b. Deductible
c. Copayment
d. Coinsurance

a. Benefit

All of the following types of procedures and services typically require prior approval except:

a. Emergency services for suspected stroke
b. Outpatient surgery
c. Mental health and chemical dependency care
d. Inpatient care including surgery
e. Physical, occupational, and speech therapies

a. Emergency services for suspected stroke

In the healthcare industry, what is the term for the written report that insurers use to notify insureds about the extent of payments made on a claim?

a. Certificate of Insurance
b. Coordination of Benefits
c. Explanation of Benefits
d. Summary of Benefits and Coverage

c. Explanation of Benefits

In the healthcare sector, what is the term for the fixed dollar amount that the guarantor pays?

a. Coinsurance
b. Copayment
c. Deductible
d. Contractual disallowance

b. Copayment

The worker had group healthcare insurance coverage through her employer. The worker's household included her spouse, two natural children (ages 28 and 12), an adopted child (age 8), a 6-month infant in the waiting period prior to adoption, and the worker's mother (age 58). Who may be included under dependent coverage in the healthcare insurance policy?

a. Spouse and one natural child age 12
b. Spouse, natural child age 12, adopted child age 8, and 6-month infant in waiting period
c. Spouse, two natural children ages 28 and 12, adopted child age 8, and 6-month infant in waiting period
d. Everyone in the household

b. Spouse, natural child age 12, adopted child age 8, and 6-month infant in waiting period

What is the term for the contract between the healthcare insurance company and the individual or group for whom the company is assuming the risk?

a. Benefit
b. Coverage
c. Rider
d. Policy

d. Policy

What is the term for the number that identifies the employer, association, or other entity purchasing the healthcare insurance and indicates a common set of healthcare benefits?

a. Subscriber
b. Standard
c. Group
d. Bin

c. Group

Which of the following characteristics is the greatest advantage of group healthcare insurance?

a. Guaranteed issue
b. Smaller risk pool
c. Greater benefits for lower premiums
d. Higher out-of-pocket expenses

c. Greater benefits for lower premiums

Which of the following entities is also known as a "group plan"?

a. Private individual healthcare insurance plan
b. Disability income protection
c. Employer-based healthcare insurance plan
d. Medicare

c. Employer-based healthcare insurance plan

Which type of healthcare insurance policy offers the widest ranging coverage but requires the insured to pay coinsurance until the maximum out-of-pocket costs are met?

a. Accidental death and dismemberment
b. Comprehensive
c. Disability income protection
d. Major medical
e. Medigap

b. Comprehensive

Which type of healthcare insurance policy provides benefits to pay for Medicare deductibles and coinsurance?

a. Accidental death and dismemberment
b. Comprehensive
c. Disability income protection
d. Major medical
e. Medigap

e. Medigap

Which type of prescription drug is the LEAST costly for insureds using their drug benefit?

a. Preferred generic
b. Preferred brand name
c. Nonpreferred
d. Specialty

a. Preferred generic

Please define each part of Medicare and list examples of what each one covers.

...

Medicare Part A

Inpatient hospital insurance, provided with no premiums to most beneficiaries. Most services require an annual deductible and copayment be paid by the beneficiary. Inpatient hospitalization Long term care hospitalization Skilled nursing facility services Home health services Hospice care

Medicare Part B

Supplemental medical insurance, optional insurance package that may be purchased. Covers physician services, medical services, and medical supplies not covered by Part A. Physician services Medical services Medical supplies

Medicare Part C

Additional coverage known as Medicare Advantage which provides services excluded from Part A and Part B. Long term care Dental service Vision services Routine examinations Acupuncture Hearing aids

Medicare Part D

Created by the Medicare Modernization Act (MMA) OF 2003 and fully implemented on January 1, 2006. Program offers outpatient drug coverage provided by private prescription drug plans and Medicare Advantage.

Why is Medicaid coverage not identical in New Jersey, California, and Idaho?

...

All of the following are true of state Medicaid programs except:

a. Federal funds allocated to each state are based on the average income per person for that state.
b. The program must cover infants born to Medicaid-eligible pregnant women.
c. States may offer a managed care option.
d. Services offered to beneficiaries are the same in each state.

d. Services offered to beneficiaries are the same in each state.

In states where there is not a mandated fund for workers' compensation which of the following is an option for employers?

a. Use the Federal program operated by the Office of Workers' Compensation Programs
b. Purchase workers' compensation insurance from a private carrier
c. Provide workers' compensation self-insurance coverage
d. Do not offer workers' compensation to their employees
e. A and B are correct
f. B and C are correct

f. B and C are correct

Medicare part C is a ___________ option known as Medicare Advantage.

a. Managed care
b. Fee for service
c. Self-insured
d. Free

a. Managed care

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is available for:

a. Veterans of the armed forces
b. Spouse or widow(er) of a veteran meeting specific criteria
c. Children of a veteran meeting specific criteria
d. Any spouse, widow(er) or children of a veteran
e. B and C

c. Children of a veteran meeting specific criteria

Which Part of the Medicare program does not include a cost-sharing provision?

a. Part A
b. Part B
c. Part C
d. Part D
e. All parts of Medicare include a cost-sharing provision.

e. All parts of Medicare include a cost-sharing provision.

Which government-sponsored program is designed to help needy families achieve self-sufficiency?

a. Medicare Part C
b. State Children's Health Insurance Program (CHIP)
c. Programs of All-Inclusive Care for the Elderly (PACE)
d. Temporary Assistance for Needy Families program (TANF)

d. Temporary Assistance for Needy Families program (TANF)

Which government-sponsored program provides coverage for the dependents of active members of the armed forces (ADFM).

a. TRICARE
b. CHAMPVA
c. Indian Health Service
d. Worker's Compensation

a. TRICARE

Which of the following is not a function of the Indian Health Service (IHS)?

a. Assists Indian tribes in the development of their own health programs
b. Facilitates and assists Indian tribes in coordinating health planning
c. Provides only inpatient healthcare services
d. Promotes using health resources available at federal, state, and local levels

c. Provides only inpatient healthcare services

Which of the following is/are true of CHIP?

a. It is a federal/state program
b. It is a state/local program
c. It varies from state to state
d. A and C are true.
e. B and C are true.

d. A and C are true.

Which of the following statements about the Veterans Health Administration is false?

a. The VA is the nation's largest integrated health care system
b. Basic eligibility includes all veterans who served in active military service regardless of the separation condition
c. VA provides services at a low cost for its members
d. VA members are divided in the Priority Groups to determine the level of covered benefits

b. Basic eligibility includes all veterans who served in active military service regardless of the separation condition

All of the following actions reflect the roles of PCPs in MCOs EXCEPT:

a. Authorize patients' visits to oncologists
b. Coordinate care of patients
c. Refer patients to colleagues for immunizations and other general care
d. Provide primary care

c. Refer patients to colleagues for immunizations and other general care

All of the following activities are service management tools used in controlling costs EXCEPT:

a. Applying an episode-of-care payment system
b. Determining medical necessity and utilization review
c. Assigning the primary care provider as gatekeeper to specialized services through referrals and prior authorizations
d. Case and prescription management

a. Applying an episode-of-care payment system

All of the following activities are steps in medical necessity and utilization review EXCEPT:

a. Initial clinical review
b. Peer clinical review
c. Appeal consideration
d. Administrative review

d. Administrative review

All of the following functions are ways that MCOs work toward their goal of quality patient care EXCEPT:

a. Applying PMPM payment system
b. Selecting providers carefully
c. Emphasizing the health of their populations
d. Using care management tools
e. Maintaining accreditation

a. Applying PMPM payment system

All of the following types of services or populations are common examples of "carve outs" EXCEPT:

a. Immunizations and well-baby care
b. Chronically ill children
c. Dental care
d. Behavioral and mental health
e. Prescription drugs

a. Immunizations and well-baby care

Evidence-based clinical guidelines originate from all the following sources EXCEPT:

a. Agency for Healthcare Research and Quality
b. Physicians' personal clinical experiences
c. Centers for Disease Control and Prevention
d. American College of Cardiology

b. Physicians' personal clinical experiences

The patient belongs to a managed care plan. The patient wants to make an appointment with an out-of-network specialist. The plan has approved the appointment as "out-of-network." What should the patient expect?

a. The front office of the out-of-network specialist will delay and obstruct the making of the appointment.
b. The patient's out-of-pocket costs for the out-of-plan appointment will be equal to the out-of-pocket costs for in-plan care because the prior notification was completed.
c. The patient's out-of-pocket costs will be increased.
d. The patient can permanently transfer his or her care to the out-of-plan specialist because the initial appointment was approved.

c. The patient's out-of-pocket costs will be increased.

What is the term for an MCO that serves Medicare beneficiaries?

a. Medicare Advantage
b. Social Foundation
c. Part A
d. Exclusive Provider Organization

a. Medicare Advantage

What term means a network of organizations that directly provides or arranges to provide a coordinated continuum of services to a defined population and takes accountability for the cost, quality, and outcomes of care?

a. Subcapitation continuum
b. Open panel
c. Community care management
d. Integrated delivery system

d. Integrated delivery system

Who are "dual eligibles"?

a. Individuals who are eligible for Medicare and have Long-Term care insurance
b. Individuals who are eligible for Medicare and Medicaid
c. Individuals who are eligible for Medicare and are institutionalized
d. Individuals who are eligible for Medicare and have a severe or disabling chronic condition

b. Individuals who are eligible for Medicare and Medicaid

Why did Congress pass the Health Maintenance Organization Act of 1973?

To encourage the delivery of affordable, quality healthcare

What is the a HMO?

Define the abbreviation and explain.

Health maintenance organization Most controlled. Organized healthcare delivery system to a geographic area. Voluntarily enrolled members and predetermined fixed periodic prepayments for members coverage.

What is the a PPO?

Define the abbreviation and explain.

Preferred Provider Organizations Least controlled. Entity that contracts with employers and insurers through a network of providers.

Both of these MCO allows patients to choose how they will receive services at the time that the patients need the service?

a. True
b. False

b. False

List at least two major reasons that Medicare administrators turned to the prospective payment concept for Medicare beneficiaries.

Medicare administrators wanted to control the rising healthcare payments, which were rising at a faster rate than US workers were contributing dollars. Medicare administrators also wanted to prevent fraud and abuse in the system.

What does a DRG stand for?

Diagnosis Related Group

What does APC stand for?

Ambulatory Payment Classification

What does TEFRA stand for?

Tax Equity Fiscal Responsibility Act

What does MCC stand for?

Major complication/comorbidity

What does CC stand for?

Complication/Comorbidity

What does RBRVS stand for?

Resource-based relative value scale

What does RVU stand for?

Relative Value Units

In Medicare's resource-based relative value scale payment system, what is the term for the national dollar amount that is annually designated to convert relative value units into dollars?

a. Conversion factor
b. Withhold rate
c. Revenue index
d. Discounting fee

a. Conversion factor

In Medicare's resource-based relative value scale payment system, which factor adjusts payments to physicians and health professionals for price differences among various parts of the country?

a. Conversion factor
b. Geographic practice cost index
c. Party liability
d. Scaling

b. Geographic practice cost index

The MS-DRG payment includes reimbursement for all of the following inpatient services except:

a. Physician hospital visit
b. Surgery
c. Laboratory tests
d. Medications

a. Physician hospital visit

What is the average of the sum of the relative weights of all patients treated during a specified time period?

a. Case mix index
b. Outlier pool
c. Share
d. Mean qualifier

a. Case mix index

What is the rate year (RY) for IPPS?

a. January - December
b. April - March
c. July - June
d. October - September

d. October - September

Which IPPS provision is provided to facilities that experience a financial hardship because they provide treatment for patients who are unable to pay for the services?

a. Underserved facility
b. Financial hardship hospital
c. Percentage income payment facility
d. Disproportionate share hospital

d. Disproportionate share hospital

Which Medicare contractor reimburses acute care hospitals on behalf of Medicare?

a. Quality improvement organization (QIO)
b. Recovery audit contractor (RAC)
c. Medicare administrative contractor (MAC)
d. All of the above

c. Medicare administrative contractor (MAC)

Which element of the relative value unit accounts for the operational costs of delivering healthcare services, such as rent, wages of technical personnel, and supplies and equipment?

a. Work value
b. Professional liability insurance
c. Geographic practice cost index
d. Practice expense

d. Practice expense

Which of the following concepts is a guiding principle for prospective payment?

a. A hospital's payment rate is determined the hospital's part or current actual costs.
b. Hospitals may balance bill the patient so that their total payment is equal to their cost for providing the care.
c. Hospitals will not suffer a loss because their costs are always covered due to balance billing and outlier payments.
d. Payment rates are established in advance of the healthcare delivery and are fixed for the fiscal period to which they apply.

d. Payment rates are established in advance of the healthcare delivery and are fixed for the fiscal period to which they apply.

Which piece of legislation called for the first hospital inpatient prospective payment system? This piece of legislation also allowed some hospital setting to retain their cost-based payment systems.

a. Tax Equity and Fiscal Responsibility Act (TEFRA)
b. Balanced Budget Act (BBA)
c. Balanced Budget Refinement Act (BBRA)
d. False Claims Act

a. Tax Equity and Fiscal Responsibility Act (TEFRA)

Which researcher is associated with Medicare's resource-based relative value scale payment system?

a. Fetter
b. Hsaio
c. Thompson
d. Weed

b. Hsaio

The MPFS stands for?

Medicare physician fee schedule

The three elements of the RVU include:

Physician work (WORK), Physician practice expense (PE), professional liability insurance (PLI) or Malpractice (MP)

Even though Medicare-severity Long-term care diagnosis related groups (MS-LTC-DRGs) are based on the same general factors as the acute-care MS-DRGs for the IPPS, MS-LTC-DRGS differ from acute-care MS-DRGs because MS-LTC-DRGs have different relative weights and use quintiles for low volumes.

a. True
b. False

a. True

What tool is used to collect information about Medicare patients that drives payment in the IRF PPS?

Inpatient rehabilitation facility patient assessment instrument (IRF PAI)

IRF staff members record RICS on patients' PAIs to classify their impairment categories.

a. True
b. False

b. False

PAC

Postacute care

Postacute care (PAC)

Provides patients with healthcare services for their recuperation and rehabilitation after an illness or injury.

PAC Settings

Skilled nursing facilities (SNFs) Long-term care hospitals (LTCH) Inpatient rehabilitation facilities (IRFs) Home health agencies (HHAs)

SNF

Skilled nursing facilities

LTCH

Long-term care hospitals

IRF

Inpatient rehabilitation facilities

HHA

Home health agencies

The code sets to be used for healthcare services reporting by both public and private insurers were designated by what legislation?

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The ICD is maintained by American Medical Association.

a. True
b. False

b. False

Individual (private) healthcare insurance is the most common means of coverage for the nonelderly in the United States.

a. True
b. False

b. False

Both parents carried healthcare insurance with dependent coverage through their employers. What procedure is used to determine which healthcare insurer is responsible for their child's health expenses?

"Birthday rule"

What is the term for the difference between the provider's actual charge and allowable charge?

Adjustment or write-off

The actual charge is the same as the allowable charge.

a. True
b. False

b. False

The patient and the guarantor are always the same person.

a. True
b. False

b. False

When CHAMPVA beneficiary reaches age 65, Medicare becomes the primary payer, and CHAMPVA becomes the secondary payer.

a. True
b. False

a. True

Services offered by IHS to Indian tribes include all of the following except

a. Rehabilitative services
b. Death benefits
c. Outpatient care
d. Development of sanitation facilities

b. Death benefits

In which type of HMO are the physicians employees?

Staff Model; most controlled

Access to mental or behavioral health or medial specialists is through referral. What is the term for the individual who makes the referral?

PCP, gatekeeper

PACE works with

Frail elderly

Dependents (children) can stay on their parents insurance until the age of

26

TEFRA was about fraud?

a. True
b. False

b. False

CMGs

Case-mix groups

Case-mix groups (CMGs)

Classify together patients or residents with similar conditions and characteristics who use similar levels of resources.

Base rate

Converts weights to dollars.

SNF PPS

Skilled nursing facility prospective payment system

Skilled nursing facility prospective payment system (SNF PPS)

Covered by Medicare Part A immediately after an acute-care inpatient hospitalization of at least three days. They may receive up to 100 days per benefit period. Pay a daily rate for each day of care (per diem). Covers costs for skilled nursing care, rehabilitation services, ancillary services, capital costs, and other goods and services.

CB

Consolidated Billing

Consolidated Billing (CB)

Requires SNF to pay for outpatient services that a resident may receive from outside vendors (laboratories, x-ray services, pharmacies)

MDS

Minimum Data Set

Minimum Data Set (MDS)

Represents clinical documentation of the resident's care. Extensive database of clinical data which is part of the resident's health record.

SNF PPS Structure Payment

Base Rate (per diem) SNF case-mix group Adjustments

Market basket

Mix of goods and services.

Market basket (price) index

Relative measure that averages the costs of an appropriate mix of goods and services for the site of care in the continuum of care.

Wage Indexes

Ratio that represents the relationship between the average wages in a healthcare setting's geographical area and the national average for that healthcare setting.

RUG

Resource Utilization Group

Resource Utilization Group (RUG)

Classification for resources used in nursing homes. Patients are classifies into one of 44 possible groups based on residents information collected from the MDS.

What tool does CMS require that SNFs use to collect and report clinical data about residents?

Minimum Data Set (MDS)

What tool does the SNF PPS use annually to adjust payment rates?

Market basket index

What cost sharing applies to beneficiaries residing in LTCH for 90 days?

Inpatient deductible must be paid for the 90-day benefit period; plus a daily co-insurance payment for days 61-90.

What converts the MS-LTC-DRG into an unadjusted payment amount?

Standard federal rate

MS-LTC-DRGs

Medicare-severity long-term care diagnosis related groups

In Medicare's prospective payment system for skilled nursing facilities, what classification is used to adjust for case mix?

RUGs

CMS analysts divide admission to skilled nursing facilities into upper and lower categories. To which of the following categories does the ""presumption of coverage"" apply

Rehabilitation Plus Extensive, Rehabilitation

What tool does CMS require that long-term care hospitals use to collect and to report clinical data on patients?

Long-term care hospitals Continuity Assessment and Record Evaluation (CARE) data set

"In Medicare's prospective payment system for long-term care hospitals, what classification is used to adjust for case mix?"

MS-LTC-DRG

A patient with which condition is an appropriate candidate for an LTCH?

Ventilator-dependent emphysema

Under Medicare's prospective payment system for long-term care hospitals, all of the following elements used to group patients into a MS-LTC-DRG except

Qualifying diagnosis at acute inpatient hospital prior to admission to LTCH

In most situations, for a facility to be defined as an LTCH, the lengths of stay of its Medicare patient must be at least how long

25 days

IRFs

Inpatient Rehabilitation Facilities

Inpatient Rehabilitation Facilities (IRFs)

Provide intense multidisciplinary services to inpatients. Purpose if to restore or enhance patient's function after injury or illness.

IRF

Freestanding hospitals Distinct specialized rehabilitation units in acute-care hospitals

Organizations excluded from IRF PPS

VA Hospitals Hospitals reimbursed under state cost-control systems or authorized demonstration projects Nonparticipating hospitals furnishing emergency services to Medicare beneficiaries.

Who authorized the development of the inpatient rehabilitation facility prospective payment system?

The Balanced Budget Act of 1997

IRF PAI

Inpatient Rehabilitation Facility Patient Assessment Instrument

Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI)

Information collect once upon admission and again at discharge that drives payment.

IRVEN

Inpatient Rehabilitation Validation and Entry

HIPPS

Health Insurance Prospective Payment System (HIPPS) code

HHAs

Home Health Agencies

OASIS

Outcome Assessment Information Set

LUPAs

Low-utilization payment adjustments

What tool is used to collect information about Medicare patients that drives payment in the IRF PPS?

Inpatient rehabilitation facility patient assesssment instrument (IRF PAI)

For inpatient rehabilitation facility patients, codes on the IRF PAI should follow the UHDDS and the UB-04 guidelines

a. True
b. False

b. False

IRF staff members record RICS on patients PAIs to classify their impairment categories.

a. True
b. False

b. False

What home health services are consolidated into a single payment to HHAs?

Therapy (speech, physical, and occupational) sessions, skilled nursing visits, home health aide visits, medical social services, and all medical supplies within a 60-day episode of care.

When is a LUPA used, and how does it affect reimbursement?

Applied when an agency provides four or fewer visits in an episode; reimbursement in this case is made for each visit rather than for the 60-day episode.

What services are included in the consolidated billing of the SNF PPS?

Laboratories, x-ray services, and pharmacies.

What services are excluded from the consolidated billing of the SNF PPS?

Emergency services, inpatient services, and other extensive procedures such as radiation therapy.

How are per diem rates for SNF PPS patients determined for various cases?

RUG classification system

For CMS to define a facility as an LTCH, how many days must its medicare patients average length of stay be?

25 days or more

How are MS-LTC-DRGs determined?

Principal diagnosis, additional diagnosis (up to 24), procedures (up to 25, sex, age, discharge status.

On the IRF PAI, the patient's ability to perform activities of daily living, or __________, is recorded on the ___________.

functional status, functional independence assessment tool

For inpatient rehabilitation facility patients, codes on the IRF PAI should follow the UHDDS and the UB-04 guidelines?

a. True
b. False

b. False

Facilities transmit IRF PAIs to Centers for Medicare and Medicaid Services using CMSs free IRVEN software.

a. True
b. False

a. True

In the HHPPS, the _________ software is used to collect and submit OASIS data.

jHAVEN

jHAVEN

Java-based home assistance validation and entry

How is durable medical equipment (DME) reimbursed in the HHPPS?

DME is excluded from the per-episode HHPPS reimbursement system and is reimbursed under the DME fee schedule.

RCM

Revenue cycle management

Revenue cycle management (RCM)

Supervision of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.

Revenue cycle

Regular set of tasks and activities producing revenue for the facility or practice, and the management of that cycle in an acute care setting.

Major components of the revenue cycle

Pre-claims submission activities Claims processing activities Accounts receivable Claims reconciliation and collections

Pre-claims submission activities

Compromise tasks and functions from the patient registration and case management areas.

Claims processing activities

Capture of all billable services, claim generation, and claim corrections.

CDM

Charge description master

Charge description master (CDM)

Large database maintained by the facility that houses the price list and require claim data elements for all services provided to patients.

MAC

Medicare Administrative Contractor

Medicare Administrative Contractor (MAC)

Determines costs and reimbursement amounts, conducts reviews and audits, and makes payments to providers for covered services on behalf of Medicare.

MSNs

Medicare summary notices

RA

Remittance Advice

Remittance Advice (RA)

Sent to providers by third party payers and outlines claim rejections, denials. and payments to the facility.

What is the first component in the revenue cycle?

Preclaims submission activities such as collecting responsible parties information, educating patients about their ultimate financial responsibility for services rendered, collecting appropriate waivers, and verifying data about procedures before they are performed and their charges submitted.

How are charges for healthcare at all of the points of services collected and reported to the appropriate patient account for entry onto the provider's claim?

Electronic order entry systems help to capture charges at their point-of-service delivery. If facilities lack electronic systems, staff collect paper-based charges on charge tickets, superbills, or encounter forms to be entered by billing staff into the patient accounting system.

What is the function of scrubbers in the claims processing component of the revenue cycle?

Scrubbers edit claims to locate and flag for correction any data that may contain errors, such as dates of service that are incompatible, inaccurate diagnosis and procedure codes, lack of substantiation of medical necessity and inaccurate assignment of revenue codes.

List the basic data elements of a CDM, identifying which data elements are hospital-specific and which are nationally recognized.

Facility-specific Charge code Department number Description Charge Nationally recognized HCPCS code Revenue code

NCDs

National Coverage Determinations

LCDs

Local Coverage Determinations

Discuss how NCDs are different from LCDs

NCDs establish coverage or noncoverage for services. LCDs communicate the circumstances under which covered services are deemed medically necessary.

Key performance indicators

Measurement tool that should represent areas that need improvement.

IRC

Integrated revenue cycle

Integrated revenue cycle (IRC)

Coordination of revenue cycle activities under a single leadership and team structure.

SMI

Outpatient service-mix index

Outpatient service-mix index (SMI)

Sum of all weights of ambulatory payment classification groups for patients treated during a given period divided by the total volume of patients treated.

Healthcare facilities should design key performance indicators so that they ____________.

can be measured to gauge performance improvement

What are three benefits of an integrated revenue cycle?

Reduced cost to collect, performance consistency, and coordinate strategic goals.

What system is typically used to audit outpatient Medicare claims?

The Medicare Outpatient Code Editor (OCE)

In MS-DRG relationships reporting, MS-DRG families are examined for ___________.

Complication and comorbidity (CC) and major complication and comorbidity (MCC) codes.

Medicare payments made under the ESRD PPS can cover dialysis services rendered to children.

a. True
b. False

a. True

In the ESRD PPS, a patient-level adjustment for adults is high body mass index

a. True
b. False

b. False

The federal 340B drug pricing program makes prescription drugs available to eligible providers at reduced cost.

a. True
b. False

a. True

FQHCs, similar to RHCs, must be established in nonurban areas.

a. True
b. False

b. False

Medicare payments for a Medicare beneficiary's hospice services terminate at six months or the beneficiary's death, whichever comes first.

a. True
b. False

b. False

In the hospice PPS, which category of care has the lowest per diem rate of reimbursement?

Routine Home Care

Medicare-certified ASCs may share recordkeeping and financial and accounting systems with hospitals in the same parent corporation.

a. True
b. False

b. False

CMS created a motivation for surgical procedures to migrate from the more expensive inpatient setting to the less expensive outpatient surgery setting without creating a motivation to shift procedures from the less expensive physician office setting to the more expensive outpatient surgery setting by creating ____________.

Revising the ASC List (allowed procedures for the ASC setting)

How are multiple and bilateral procedures adjusted in the ASC PPS?

The second procedure is discounted or reduced by 50%

Which three modifiers are utilized for interrupted procedures in the ASC setting?

73, 74, and 52

Because the ASC PPS uses the same APCs groups as the OPPS, the payment rates for the ASC setting are the same as the hospital outpatient setting.

a. True
b. False

b. False

VBP

Value-based purchasing

P4P

Pay-for-performance

Definitions of VBP

Measurement, transparency, and accountability.

Measurement

Stakeholders, such as patients, consumers, payers, and other decision makers must have facts.

Transparency

Skateholders need information about the cost and quality of healthcare so that they can make informed choices.

Accountability

Holds individuals and organizations responsible for their actions.

Pay-for-performance (P4P)

Any type of payment arrangement to reimburse providers that is performance-based and that includes incentives with contractually-specified performance targets.

Value-based purchasing (VBP)

A system in which purchasers hold providers of healthcare accountable for both the costs of healthcare and its quality.

Targets

Specific, measurable objectives against which performance can be judged. Ex: maintaining or improving the quality of care or meeting benchmarks on profitability or efficiency.

Purchasers

Public and private sector entities that subsidize, arrange and contract for and in many bear the risk for the cost of healthcare services received by a group.

Value

Focusing on both quality and cost at the same time in purchasing and delivering healthcare.

What three components do value-based purchasing (VBP) systems and pay-for-performance (P4P) systems typically link?

Quality, performance, and payment

What three reports provided the impetus for VBP/P4P systems?

To Err Is Human Crossing the quality chasm Rewarding Provider Performance

VBP/P4P systems only include financial rewards.

a. True
b. False

b. False

VBP/P4P systems have been slow in getting established since 2004.

a. True
b. False

b. False

What are two major categories of VBP/P4P models?

Reward-based models and penalty-based models

What targets should be the focus of VBP/P4P systems?

Most significant problems in terms of quality or cost, proportion of population covered by the service or provider, and availability of valid and reliable performance measures.

The very first pay-for-performance systems emerged in the early 1990s.

a. True
b. False

b. False

What is attribution and by what other terms is this process known?

Attribution is the determination of who rendered care so that the care's outcomes can be linked to its provider and that provider receives the reward or penalty. Other terms for attribution are enrollee assignment or beneficiary assignment.

The Centers for Medicare and Medicaid Services has attempted to 'brake' the pay-for-performance and value-based purchasing systems trend because its experts believe the linkage of quality and rewards jeopardizes the care of patients

a. True
b. False

b. False

List three other countries that are investigating or have implemented pay-for-performance systems for their healthcare delivery systems.

Australia, Canada, Great Britain

Withholding compensation would be considered a penalty-based model of pay-for-performance.

a. True
b. False

a. True

What piece of legislation mandated CMS to develop a value-based purchasing system?

Deficit Reduction Act of 2005

What type of VBP program is the Hospital Acquired Conditions Reduction Program?

Paying for Value.

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In which type of reimbursement methodology does the health insurance company have the greatest degree of risk?

a. Capitated payment
b. Global payment
c. Block grant
d. Retrospective

d. Retrospective

In the healthcare industry, what is another term for "fee"?

a. Capitated rate
b. Charge
c. Discount
d. Reimbursement

b. Charge

In the United States, what is healthcare insurance?

a. Federal program to provide medical care and services to indigent US citizens
b. State programs to provide medical care and services to deserving individuals
c. 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
d. Set of negotiated guarantees that all healthcare expenses of a risk pool will be covered by employers

c. 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

All of the following phenomena are considered "life events" except:

a. Birth
b. Marriage
c. Adoption of a child
d. Illness

d. Illness

To which of the following factors is health insurance status most closely linked?

a. Access
b. Employment
c. Gender
d. Need

b. Employment

Which of the following coding systems was created for reporting procedures and services performed by physicians in clinical practice?

a. ICD-9-CM
b. CPT
c. ICD-10-PCS
d. HCPCS Level II

b. CPT

In the healthcare sector, what is the term for a group of individual entities, such as individual persons, employers, or associations, whose healthcare costs are combined for evaluating financial history and estimating future costs?

a. Limitation
b. Risk pool
c. In-network
d. Wrap-around

b. Risk pool

An annual amount of money that the policyholder must incur (and pay) before the health insurance will assume liability for the remaining charges or covered expenses is known as a _____________

deductible

Explain Risk Pools, how they work and what are the pros and cons.

Group of individual entities, such as individual persons, employers, or associations, whose healthcare costs are combined for evaluating financial history and estimating future costs. Large-employer pools: Employees of one employer, typically 1,000 members or more. Large and diverse. Multiple-employer pools: Employees from several midsize employers or small employers or groups of association. Smaller and less diverse than the large-employer pool. Individual Pools: Self-employed people or people who work for companies that do not offer healthcare insurance. Least diverse because people tend to be similar.

The coding system that is used primarily for reporting diagnoses for hospital inpatients is known as:

a. ICD-10-CM
b. CPT
c. ICD-10-PCS
d. HCPCS Level II

a. ICD-10-CM

Which type of healthcare insurance policy provides benefits to a resident requiring nursing home care and services?

a. Long-term or extended care insurance
b. Accidental death and dismemberment insurance
c. Disability income protection insurance
d. Major medical
e. Medigap

a. Long-term or extended care insurance

What is an Explanation of Benefits (EOB)?

Report sent from a healthcare insurer to the policyholder and to the provider that describes the healthcare service, its costs, applicable cost sharing, and the amount the healthcare insurer will cover. The remainder is the policyholder’s responsibility.

What healthcare organization is one of the most influential in the healthcare sector because it insures nearly one in three Americans?

a. Blue Cross Blue Shield
b. Center of Excellence
c. Title 1
d. American Hospital Association

a. Blue Cross Blue Shield

All of the following specifications are types of limitations on healthcare policies except:

a. Benefit cap
b. Cost-sharing provision
c. Geographic plan
d. Use of formulary

c. Geographic plan

A covered service for which the health care company will pay is known as a___________

Benefit

In the healthcare industry, what is the term for receiving compensation for healthcare services that were previously provided?

a. Fee schedule
b. Recompense
c. Reimbursement
d. Render

c. Reimbursement

Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to calculate the group’s premiums?

a. To increase premium payments for insurance plan payers
b. To simplify accounting for the group’s plan
c. To assure that the pool is large enough to pay losses of the entire group
d. A and B only
e. All of the above

c. To assure that the pool is large enough to pay losses of the entire group

Where did health insurance become established in the United States?

Texas; 1929

The federal role in the healthcare sector is limited to paying providers for the healthcare costs of senior citizens.

a. True
b. False

b. False

What is the purpose of managed care?

To reduce the cost of healthcare services and to improve the quality of care for patients.

The constant trend of increased national spending on healthcare is a concern because as spending on healthcare increases, the money available for other sectors of the economy decreases.

a. True
b. False

a. True

In the accounting system of the physician office, the account is categorized as "self-pay." How should the insurance analyst interpret this category?

a. The employer’s self-insured healthcare insurance plan will cover the account.
b. The physician, himself or herself, will pick up the balance of the bill.
c. The guarantor will pay the entire bill.
d. The patient will pay deductibles and non-covered charges.

c. The guarantor will pay the entire bill.

In the healthcare insurance sector, what does UCR stand for?

a. Uniform Crime Report
b. Usual Customary and Reasonable
c. Universal and Common Rates
d. Usable Capital Receipts

b. Usual Customary and Reasonable

In which type of reimbursement methodology do healthcare insurance companies determine payment to providers before the services have been delivered?

a. Block grant
b. Global payment
c. Prospective payment
d. Retrospective payment

c. Prospective payment

There are 3 parties in healthcare reimbursement. Who is the first party?

a. Patient or guarantor
b. Provider of care or services
c. Payer
d. Society

a. Patient or guarantor

There are 3 parties in healthcare reimbursement. Who is the second party?

a. Patient or guarantor
b. Provider of care or services
c. Payer
d. Society

b. Provider of care or services

There are 3 parties in healthcare reimbursement. Who is the third party?

a. Patient or guarantor
b. Provider of care or services
c. Payer
d. Society

c. Payer

Which national model for the delivery of healthcare services is financed by general revenue funds from taxes?

a. Social insurance (Bismarck) model
b. National health service (Beveridge) model
c. Private health insurance model
d. A and B only
e. All of the above

b. National health service (Beveridge) model

Which type of reimbursement methodology is associated with the abbreviation "PMPM"?

a. Capitated payment
b. Global payment
c. Block grant
d. Retrospective

a. Capitated payment

All of the following are efforts to fight healthcare fraud and abuse except:

a. Operation Restore Trust
b. Medicare Integrity Program
c. Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
d. Medicare and Medicaid Patient and Program Protection Act of 1987

c. Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

Common forms of fraud and abuse include all of the following except:

a. Upcoding
b. Unbundling
c. Refiling claims after denials
d. Billing for services not furnished to patients

c. Refiling claims after denials

When people purchase healthcare insurance for themselves and their dependents, they are purchasing single coverage. True or false?

a. True
b. False

b. False

In terms of healthcare insurance coverage, both children and spouses may be considered dependents.

a. True
b. False

a. True

What organization is one of the most influential in the healthcare sector?

Blue Cross Blue Shield

The female worker was just married on July 1, 2016. She had worked for the organization for the past 8 years and has been covered under its group healthcare insurance policy during the entire period. She is ONLY allowed to add her new spouse during open enrollment which, for this organization, is October 1, 2016 through November 1, 2016 becoming effective on January 1, 2017.

a. True
b. False

b. False

All of the following are cost-sharing provisions except:

a. Benefit
b. Deductible
c. Copayment
d. Coinsurance

a. Benefit

All of the following types of procedures and services typically require prior approval except:

a. Emergency services for suspected stroke
b. Outpatient surgery
c. Mental health and chemical dependency care
d. Inpatient care including surgery
e. Physical, occupational, and speech therapies

a. Emergency services for suspected stroke

In the healthcare industry, what is the term for the written report that insurers use to notify insureds about the extent of payments made on a claim?

a. Certificate of Insurance
b. Coordination of Benefits
c. Explanation of Benefits
d. Summary of Benefits and Coverage

c. Explanation of Benefits

In the healthcare sector, what is the term for the fixed dollar amount that the guarantor pays?

a. Coinsurance
b. Copayment
c. Deductible
d. Contractual disallowance

b. Copayment

The worker had group healthcare insurance coverage through her employer. The worker’s household included her spouse, two natural children (ages 28 and 12), an adopted child (age 8), a 6-month infant in the waiting period prior to adoption, and the worker’s mother (age 58). Who may be included under dependent coverage in the healthcare insurance policy?

a. Spouse and one natural child age 12
b. Spouse, natural child age 12, adopted child age 8, and 6-month infant in waiting period
c. Spouse, two natural children ages 28 and 12, adopted child age 8, and 6-month infant in waiting period
d. Everyone in the household

b. Spouse, natural child age 12, adopted child age 8, and 6-month infant in waiting period

What is the term for the contract between the healthcare insurance company and the individual or group for whom the company is assuming the risk?

a. Benefit
b. Coverage
c. Rider
d. Policy

d. Policy

What is the term for the number that identifies the employer, association, or other entity purchasing the healthcare insurance and indicates a common set of healthcare benefits?

a. Subscriber
b. Standard
c. Group
d. Bin

c. Group

Which of the following characteristics is the greatest advantage of group healthcare insurance?

a. Guaranteed issue
b. Smaller risk pool
c. Greater benefits for lower premiums
d. Higher out-of-pocket expenses

c. Greater benefits for lower premiums

Which of the following entities is also known as a "group plan"?

a. Private individual healthcare insurance plan
b. Disability income protection
c. Employer-based healthcare insurance plan
d. Medicare

c. Employer-based healthcare insurance plan

Which type of healthcare insurance policy offers the widest ranging coverage but requires the insured to pay coinsurance until the maximum out-of-pocket costs are met?

a. Accidental death and dismemberment
b. Comprehensive
c. Disability income protection
d. Major medical
e. Medigap

b. Comprehensive

Which type of healthcare insurance policy provides benefits to pay for Medicare deductibles and coinsurance?

a. Accidental death and dismemberment
b. Comprehensive
c. Disability income protection
d. Major medical
e. Medigap

e. Medigap

Which type of prescription drug is the LEAST costly for insureds using their drug benefit?

a. Preferred generic
b. Preferred brand name
c. Nonpreferred
d. Specialty

a. Preferred generic

Please define each part of Medicare and list examples of what each one covers.

Medicare Part A

Inpatient hospital insurance, provided with no premiums to most beneficiaries. Most services require an annual deductible and copayment be paid by the beneficiary. Inpatient hospitalization Long term care hospitalization Skilled nursing facility services Home health services Hospice care

Medicare Part B

Supplemental medical insurance, optional insurance package that may be purchased. Covers physician services, medical services, and medical supplies not covered by Part A. Physician services Medical services Medical supplies

Medicare Part C

Additional coverage known as Medicare Advantage which provides services excluded from Part A and Part B. Long term care Dental service Vision services Routine examinations Acupuncture Hearing aids

Medicare Part D

Created by the Medicare Modernization Act (MMA) OF 2003 and fully implemented on January 1, 2006. Program offers outpatient drug coverage provided by private prescription drug plans and Medicare Advantage.

Why is Medicaid coverage not identical in New Jersey, California, and Idaho?

All of the following are true of state Medicaid programs except:

a. Federal funds allocated to each state are based on the average income per person for that state.
b. The program must cover infants born to Medicaid-eligible pregnant women.
c. States may offer a managed care option.
d. Services offered to beneficiaries are the same in each state.

d. Services offered to beneficiaries are the same in each state.

In states where there is not a mandated fund for workers’ compensation which of the following is an option for employers?

a. Use the Federal program operated by the Office of Workers’ Compensation Programs
b. Purchase workers’ compensation insurance from a private carrier
c. Provide workers’ compensation self-insurance coverage
d. Do not offer workers’ compensation to their employees
e. A and B are correct
f. B and C are correct

f. B and C are correct

Medicare part C is a ___________ option known as Medicare Advantage.

a. Managed care
b. Fee for service
c. Self-insured
d. Free

a. Managed care

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is available for:

a. Veterans of the armed forces
b. Spouse or widow(er) of a veteran meeting specific criteria
c. Children of a veteran meeting specific criteria
d. Any spouse, widow(er) or children of a veteran
e. B and C

c. Children of a veteran meeting specific criteria

Which Part of the Medicare program does not include a cost-sharing provision?

a. Part A
b. Part B
c. Part C
d. Part D
e. All parts of Medicare include a cost-sharing provision.

e. All parts of Medicare include a cost-sharing provision.

Which government-sponsored program is designed to help needy families achieve self-sufficiency?

a. Medicare Part C
b. State Children’s Health Insurance Program (CHIP)
c. Programs of All-Inclusive Care for the Elderly (PACE)
d. Temporary Assistance for Needy Families program (TANF)

d. Temporary Assistance for Needy Families program (TANF)

Which government-sponsored program provides coverage for the dependents of active members of the armed forces (ADFM).

a. TRICARE
b. CHAMPVA
c. Indian Health Service
d. Worker’s Compensation

a. TRICARE

Which of the following is not a function of the Indian Health Service (IHS)?

a. Assists Indian tribes in the development of their own health programs
b. Facilitates and assists Indian tribes in coordinating health planning
c. Provides only inpatient healthcare services
d. Promotes using health resources available at federal, state, and local levels

c. Provides only inpatient healthcare services

Which of the following is/are true of CHIP?

a. It is a federal/state program
b. It is a state/local program
c. It varies from state to state
d. A and C are true.
e. B and C are true.

d. A and C are true.

Which of the following statements about the Veterans Health Administration is false?

a. The VA is the nation’s largest integrated health care system
b. Basic eligibility includes all veterans who served in active military service regardless of the separation condition
c. VA provides services at a low cost for its members
d. VA members are divided in the Priority Groups to determine the level of covered benefits

b. Basic eligibility includes all veterans who served in active military service regardless of the separation condition

All of the following actions reflect the roles of PCPs in MCOs EXCEPT:

a. Authorize patients’ visits to oncologists
b. Coordinate care of patients
c. Refer patients to colleagues for immunizations and other general care
d. Provide primary care

c. Refer patients to colleagues for immunizations and other general care

All of the following activities are service management tools used in controlling costs EXCEPT:

a. Applying an episode-of-care payment system
b. Determining medical necessity and utilization review
c. Assigning the primary care provider as gatekeeper to specialized services through referrals and prior authorizations
d. Case and prescription management

a. Applying an episode-of-care payment system

All of the following activities are steps in medical necessity and utilization review EXCEPT:

a. Initial clinical review
b. Peer clinical review
c. Appeal consideration
d. Administrative review

d. Administrative review

All of the following functions are ways that MCOs work toward their goal of quality patient care EXCEPT:

a. Applying PMPM payment system
b. Selecting providers carefully
c. Emphasizing the health of their populations
d. Using care management tools
e. Maintaining accreditation

a. Applying PMPM payment system

All of the following types of services or populations are common examples of "carve outs" EXCEPT:

a. Immunizations and well-baby care
b. Chronically ill children
c. Dental care
d. Behavioral and mental health
e. Prescription drugs

a. Immunizations and well-baby care

Evidence-based clinical guidelines originate from all the following sources EXCEPT:

a. Agency for Healthcare Research and Quality
b. Physicians’ personal clinical experiences
c. Centers for Disease Control and Prevention
d. American College of Cardiology

b. Physicians’ personal clinical experiences

The patient belongs to a managed care plan. The patient wants to make an appointment with an out-of-network specialist. The plan has approved the appointment as "out-of-network." What should the patient expect?

a. The front office of the out-of-network specialist will delay and obstruct the making of the appointment.
b. The patient’s out-of-pocket costs for the out-of-plan appointment will be equal to the out-of-pocket costs for in-plan care because the prior notification was completed.
c. The patient’s out-of-pocket costs will be increased.
d. The patient can permanently transfer his or her care to the out-of-plan specialist because the initial appointment was approved.

c. The patient’s out-of-pocket costs will be increased.

What is the term for an MCO that serves Medicare beneficiaries?

a. Medicare Advantage
b. Social Foundation
c. Part A
d. Exclusive Provider Organization

a. Medicare Advantage

What term means a network of organizations that directly provides or arranges to provide a coordinated continuum of services to a defined population and takes accountability for the cost, quality, and outcomes of care?

a. Subcapitation continuum
b. Open panel
c. Community care management
d. Integrated delivery system

d. Integrated delivery system

Who are "dual eligibles"?

a. Individuals who are eligible for Medicare and have Long-Term care insurance
b. Individuals who are eligible for Medicare and Medicaid
c. Individuals who are eligible for Medicare and are institutionalized
d. Individuals who are eligible for Medicare and have a severe or disabling chronic condition

b. Individuals who are eligible for Medicare and Medicaid

Why did Congress pass the Health Maintenance Organization Act of 1973?

To encourage the delivery of affordable, quality healthcare

What is the a HMO?

Define the abbreviation and explain.

Health maintenance organization Most controlled. Organized healthcare delivery system to a geographic area. Voluntarily enrolled members and predetermined fixed periodic prepayments for members coverage.

What is the a PPO?

Define the abbreviation and explain.

Preferred Provider Organizations Least controlled. Entity that contracts with employers and insurers through a network of providers.

Both of these MCO allows patients to choose how they will receive services at the time that the patients need the service?

a. True
b. False

b. False

List at least two major reasons that Medicare administrators turned to the prospective payment concept for Medicare beneficiaries.

Medicare administrators wanted to control the rising healthcare payments, which were rising at a faster rate than US workers were contributing dollars. Medicare administrators also wanted to prevent fraud and abuse in the system.

What does a DRG stand for?

Diagnosis Related Group

What does APC stand for?

Ambulatory Payment Classification

What does TEFRA stand for?

Tax Equity Fiscal Responsibility Act

What does MCC stand for?

Major complication/comorbidity

What does CC stand for?

Complication/Comorbidity

What does RBRVS stand for?

Resource-based relative value scale

What does RVU stand for?

Relative Value Units

In Medicare’s resource-based relative value scale payment system, what is the term for the national dollar amount that is annually designated to convert relative value units into dollars?

a. Conversion factor
b. Withhold rate
c. Revenue index
d. Discounting fee

a. Conversion factor

In Medicare’s resource-based relative value scale payment system, which factor adjusts payments to physicians and health professionals for price differences among various parts of the country?

a. Conversion factor
b. Geographic practice cost index
c. Party liability
d. Scaling

b. Geographic practice cost index

The MS-DRG payment includes reimbursement for all of the following inpatient services except:

a. Physician hospital visit
b. Surgery
c. Laboratory tests
d. Medications

a. Physician hospital visit

What is the average of the sum of the relative weights of all patients treated during a specified time period?

a. Case mix index
b. Outlier pool
c. Share
d. Mean qualifier

a. Case mix index

What is the rate year (RY) for IPPS?

a. January – December
b. April – March
c. July – June
d. October – September

d. October – September

Which IPPS provision is provided to facilities that experience a financial hardship because they provide treatment for patients who are unable to pay for the services?

a. Underserved facility
b. Financial hardship hospital
c. Percentage income payment facility
d. Disproportionate share hospital

d. Disproportionate share hospital

Which Medicare contractor reimburses acute care hospitals on behalf of Medicare?

a. Quality improvement organization (QIO)
b. Recovery audit contractor (RAC)
c. Medicare administrative contractor (MAC)
d. All of the above

c. Medicare administrative contractor (MAC)

Which element of the relative value unit accounts for the operational costs of delivering healthcare services, such as rent, wages of technical personnel, and supplies and equipment?

a. Work value
b. Professional liability insurance
c. Geographic practice cost index
d. Practice expense

d. Practice expense

Which of the following concepts is a guiding principle for prospective payment?

a. A hospital’s payment rate is determined the hospital’s part or current actual costs.
b. Hospitals may balance bill the patient so that their total payment is equal to their cost for providing the care.
c. Hospitals will not suffer a loss because their costs are always covered due to balance billing and outlier payments.
d. Payment rates are established in advance of the healthcare delivery and are fixed for the fiscal period to which they apply.

d. Payment rates are established in advance of the healthcare delivery and are fixed for the fiscal period to which they apply.

Which piece of legislation called for the first hospital inpatient prospective payment system? This piece of legislation also allowed some hospital setting to retain their cost-based payment systems.

a. Tax Equity and Fiscal Responsibility Act (TEFRA)
b. Balanced Budget Act (BBA)
c. Balanced Budget Refinement Act (BBRA)
d. False Claims Act

a. Tax Equity and Fiscal Responsibility Act (TEFRA)

Which researcher is associated with Medicare’s resource-based relative value scale payment system?

a. Fetter
b. Hsaio
c. Thompson
d. Weed

b. Hsaio

The MPFS stands for?

Medicare physician fee schedule

The three elements of the RVU include:

Physician work (WORK), Physician practice expense (PE), professional liability insurance (PLI) or Malpractice (MP)

Even though Medicare-severity Long-term care diagnosis related groups (MS-LTC-DRGs) are based on the same general factors as the acute-care MS-DRGs for the IPPS, MS-LTC-DRGS differ from acute-care MS-DRGs because MS-LTC-DRGs have different relative weights and use quintiles for low volumes.

a. True
b. False

a. True

What tool is used to collect information about Medicare patients that drives payment in the IRF PPS?

Inpatient rehabilitation facility patient assessment instrument (IRF PAI)

IRF staff members record RICS on patients’ PAIs to classify their impairment categories.

a. True
b. False

b. False

PAC

Postacute care

Postacute care (PAC)

Provides patients with healthcare services for their recuperation and rehabilitation after an illness or injury.

PAC Settings

Skilled nursing facilities (SNFs) Long-term care hospitals (LTCH) Inpatient rehabilitation facilities (IRFs) Home health agencies (HHAs)

SNF

Skilled nursing facilities

LTCH

Long-term care hospitals

IRF

Inpatient rehabilitation facilities

HHA

Home health agencies

The code sets to be used for healthcare services reporting by both public and private insurers were designated by what legislation?

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The ICD is maintained by American Medical Association.

a. True
b. False

b. False

Individual (private) healthcare insurance is the most common means of coverage for the nonelderly in the United States.

a. True
b. False

b. False

Both parents carried healthcare insurance with dependent coverage through their employers. What procedure is used to determine which healthcare insurer is responsible for their child’s health expenses?

"Birthday rule"

What is the term for the difference between the provider’s actual charge and allowable charge?

Adjustment or write-off

The actual charge is the same as the allowable charge.

a. True
b. False

b. False

The patient and the guarantor are always the same person.

a. True
b. False

b. False

When CHAMPVA beneficiary reaches age 65, Medicare becomes the primary payer, and CHAMPVA becomes the secondary payer.

a. True
b. False

a. True

Services offered by IHS to Indian tribes include all of the following except

a. Rehabilitative services
b. Death benefits
c. Outpatient care
d. Development of sanitation facilities

b. Death benefits

In which type of HMO are the physicians employees?

Staff Model; most controlled

Access to mental or behavioral health or medial specialists is through referral. What is the term for the individual who makes the referral?

PCP, gatekeeper

PACE works with

Frail elderly

Dependents (children) can stay on their parents insurance until the age of

26

TEFRA was about fraud?

a. True
b. False

b. False

CMGs

Case-mix groups

Case-mix groups (CMGs)

Classify together patients or residents with similar conditions and characteristics who use similar levels of resources.

Base rate

Converts weights to dollars.

SNF PPS

Skilled nursing facility prospective payment system

Skilled nursing facility prospective payment system (SNF PPS)

Covered by Medicare Part A immediately after an acute-care inpatient hospitalization of at least three days. They may receive up to 100 days per benefit period. Pay a daily rate for each day of care (per diem). Covers costs for skilled nursing care, rehabilitation services, ancillary services, capital costs, and other goods and services.

CB

Consolidated Billing

Consolidated Billing (CB)

Requires SNF to pay for outpatient services that a resident may receive from outside vendors (laboratories, x-ray services, pharmacies)

MDS

Minimum Data Set

Minimum Data Set (MDS)

Represents clinical documentation of the resident’s care. Extensive database of clinical data which is part of the resident’s health record.

SNF PPS Structure Payment

Base Rate (per diem) SNF case-mix group Adjustments

Market basket

Mix of goods and services.

Market basket (price) index

Relative measure that averages the costs of an appropriate mix of goods and services for the site of care in the continuum of care.

Wage Indexes

Ratio that represents the relationship between the average wages in a healthcare setting’s geographical area and the national average for that healthcare setting.

RUG

Resource Utilization Group

Resource Utilization Group (RUG)

Classification for resources used in nursing homes. Patients are classifies into one of 44 possible groups based on residents information collected from the MDS.

What tool does CMS require that SNFs use to collect and report clinical data about residents?

Minimum Data Set (MDS)

What tool does the SNF PPS use annually to adjust payment rates?

Market basket index

What cost sharing applies to beneficiaries residing in LTCH for 90 days?

Inpatient deductible must be paid for the 90-day benefit period; plus a daily co-insurance payment for days 61-90.

What converts the MS-LTC-DRG into an unadjusted payment amount?

Standard federal rate

MS-LTC-DRGs

Medicare-severity long-term care diagnosis related groups

In Medicare’s prospective payment system for skilled nursing facilities, what classification is used to adjust for case mix?

RUGs

CMS analysts divide admission to skilled nursing facilities into upper and lower categories. To which of the following categories does the ""presumption of coverage"" apply

Rehabilitation Plus Extensive, Rehabilitation

What tool does CMS require that long-term care hospitals use to collect and to report clinical data on patients?

Long-term care hospitals Continuity Assessment and Record Evaluation (CARE) data set

"In Medicare’s prospective payment system for long-term care hospitals, what classification is used to adjust for case mix?"

MS-LTC-DRG

A patient with which condition is an appropriate candidate for an LTCH?

Ventilator-dependent emphysema

Under Medicare’s prospective payment system for long-term care hospitals, all of the following elements used to group patients into a MS-LTC-DRG except

Qualifying diagnosis at acute inpatient hospital prior to admission to LTCH

In most situations, for a facility to be defined as an LTCH, the lengths of stay of its Medicare patient must be at least how long

25 days

IRFs

Inpatient Rehabilitation Facilities

Inpatient Rehabilitation Facilities (IRFs)

Provide intense multidisciplinary services to inpatients. Purpose if to restore or enhance patient’s function after injury or illness.

IRF

Freestanding hospitals Distinct specialized rehabilitation units in acute-care hospitals

Organizations excluded from IRF PPS

VA Hospitals Hospitals reimbursed under state cost-control systems or authorized demonstration projects Nonparticipating hospitals furnishing emergency services to Medicare beneficiaries.

Who authorized the development of the inpatient rehabilitation facility prospective payment system?

The Balanced Budget Act of 1997

IRF PAI

Inpatient Rehabilitation Facility Patient Assessment Instrument

Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI)

Information collect once upon admission and again at discharge that drives payment.

IRVEN

Inpatient Rehabilitation Validation and Entry

HIPPS

Health Insurance Prospective Payment System (HIPPS) code

HHAs

Home Health Agencies

OASIS

Outcome Assessment Information Set

LUPAs

Low-utilization payment adjustments

What tool is used to collect information about Medicare patients that drives payment in the IRF PPS?

Inpatient rehabilitation facility patient assesssment instrument (IRF PAI)

For inpatient rehabilitation facility patients, codes on the IRF PAI should follow the UHDDS and the UB-04 guidelines

a. True
b. False

b. False

IRF staff members record RICS on patients PAIs to classify their impairment categories.

a. True
b. False

b. False

What home health services are consolidated into a single payment to HHAs?

Therapy (speech, physical, and occupational) sessions, skilled nursing visits, home health aide visits, medical social services, and all medical supplies within a 60-day episode of care.

When is a LUPA used, and how does it affect reimbursement?

Applied when an agency provides four or fewer visits in an episode; reimbursement in this case is made for each visit rather than for the 60-day episode.

What services are included in the consolidated billing of the SNF PPS?

Laboratories, x-ray services, and pharmacies.

What services are excluded from the consolidated billing of the SNF PPS?

Emergency services, inpatient services, and other extensive procedures such as radiation therapy.

How are per diem rates for SNF PPS patients determined for various cases?

RUG classification system

For CMS to define a facility as an LTCH, how many days must its medicare patients average length of stay be?

25 days or more

How are MS-LTC-DRGs determined?

Principal diagnosis, additional diagnosis (up to 24), procedures (up to 25, sex, age, discharge status.

On the IRF PAI, the patient’s ability to perform activities of daily living, or __________, is recorded on the ___________.

functional status, functional independence assessment tool

For inpatient rehabilitation facility patients, codes on the IRF PAI should follow the UHDDS and the UB-04 guidelines?

a. True
b. False

b. False

Facilities transmit IRF PAIs to Centers for Medicare and Medicaid Services using CMSs free IRVEN software.

a. True
b. False

a. True

In the HHPPS, the _________ software is used to collect and submit OASIS data.

jHAVEN

jHAVEN

Java-based home assistance validation and entry

How is durable medical equipment (DME) reimbursed in the HHPPS?

DME is excluded from the per-episode HHPPS reimbursement system and is reimbursed under the DME fee schedule.

RCM

Revenue cycle management

Revenue cycle management (RCM)

Supervision of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.

Revenue cycle

Regular set of tasks and activities producing revenue for the facility or practice, and the management of that cycle in an acute care setting.

Major components of the revenue cycle

Pre-claims submission activities Claims processing activities Accounts receivable Claims reconciliation and collections

Pre-claims submission activities

Compromise tasks and functions from the patient registration and case management areas.

Claims processing activities

Capture of all billable services, claim generation, and claim corrections.

CDM

Charge description master

Charge description master (CDM)

Large database maintained by the facility that houses the price list and require claim data elements for all services provided to patients.

MAC

Medicare Administrative Contractor

Medicare Administrative Contractor (MAC)

Determines costs and reimbursement amounts, conducts reviews and audits, and makes payments to providers for covered services on behalf of Medicare.

MSNs

Medicare summary notices

RA

Remittance Advice

Remittance Advice (RA)

Sent to providers by third party payers and outlines claim rejections, denials. and payments to the facility.

What is the first component in the revenue cycle?

Preclaims submission activities such as collecting responsible parties information, educating patients about their ultimate financial responsibility for services rendered, collecting appropriate waivers, and verifying data about procedures before they are performed and their charges submitted.

How are charges for healthcare at all of the points of services collected and reported to the appropriate patient account for entry onto the provider’s claim?

Electronic order entry systems help to capture charges at their point-of-service delivery. If facilities lack electronic systems, staff collect paper-based charges on charge tickets, superbills, or encounter forms to be entered by billing staff into the patient accounting system.

What is the function of scrubbers in the claims processing component of the revenue cycle?

Scrubbers edit claims to locate and flag for correction any data that may contain errors, such as dates of service that are incompatible, inaccurate diagnosis and procedure codes, lack of substantiation of medical necessity and inaccurate assignment of revenue codes.

List the basic data elements of a CDM, identifying which data elements are hospital-specific and which are nationally recognized.

Facility-specific Charge code Department number Description Charge Nationally recognized HCPCS code Revenue code

NCDs

National Coverage Determinations

LCDs

Local Coverage Determinations

Discuss how NCDs are different from LCDs

NCDs establish coverage or noncoverage for services. LCDs communicate the circumstances under which covered services are deemed medically necessary.

Key performance indicators

Measurement tool that should represent areas that need improvement.

IRC

Integrated revenue cycle

Integrated revenue cycle (IRC)

Coordination of revenue cycle activities under a single leadership and team structure.

SMI

Outpatient service-mix index

Outpatient service-mix index (SMI)

Sum of all weights of ambulatory payment classification groups for patients treated during a given period divided by the total volume of patients treated.

Healthcare facilities should design key performance indicators so that they ____________.

can be measured to gauge performance improvement

What are three benefits of an integrated revenue cycle?

Reduced cost to collect, performance consistency, and coordinate strategic goals.

What system is typically used to audit outpatient Medicare claims?

The Medicare Outpatient Code Editor (OCE)

In MS-DRG relationships reporting, MS-DRG families are examined for ___________.

Complication and comorbidity (CC) and major complication and comorbidity (MCC) codes.

Medicare payments made under the ESRD PPS can cover dialysis services rendered to children.

a. True
b. False

a. True

In the ESRD PPS, a patient-level adjustment for adults is high body mass index

a. True
b. False

b. False

The federal 340B drug pricing program makes prescription drugs available to eligible providers at reduced cost.

a. True
b. False

a. True

FQHCs, similar to RHCs, must be established in nonurban areas.

a. True
b. False

b. False

Medicare payments for a Medicare beneficiary’s hospice services terminate at six months or the beneficiary’s death, whichever comes first.

a. True
b. False

b. False

In the hospice PPS, which category of care has the lowest per diem rate of reimbursement?

Routine Home Care

Medicare-certified ASCs may share recordkeeping and financial and accounting systems with hospitals in the same parent corporation.

a. True
b. False

b. False

CMS created a motivation for surgical procedures to migrate from the more expensive inpatient setting to the less expensive outpatient surgery setting without creating a motivation to shift procedures from the less expensive physician office setting to the more expensive outpatient surgery setting by creating ____________.

Revising the ASC List (allowed procedures for the ASC setting)

How are multiple and bilateral procedures adjusted in the ASC PPS?

The second procedure is discounted or reduced by 50%

Which three modifiers are utilized for interrupted procedures in the ASC setting?

73, 74, and 52

Because the ASC PPS uses the same APCs groups as the OPPS, the payment rates for the ASC setting are the same as the hospital outpatient setting.

a. True
b. False

b. False

VBP

Value-based purchasing

P4P

Pay-for-performance

Definitions of VBP

Measurement, transparency, and accountability.

Measurement

Stakeholders, such as patients, consumers, payers, and other decision makers must have facts.

Transparency

Skateholders need information about the cost and quality of healthcare so that they can make informed choices.

Accountability

Holds individuals and organizations responsible for their actions.

Pay-for-performance (P4P)

Any type of payment arrangement to reimburse providers that is performance-based and that includes incentives with contractually-specified performance targets.

Value-based purchasing (VBP)

A system in which purchasers hold providers of healthcare accountable for both the costs of healthcare and its quality.

Targets

Specific, measurable objectives against which performance can be judged. Ex: maintaining or improving the quality of care or meeting benchmarks on profitability or efficiency.

Purchasers

Public and private sector entities that subsidize, arrange and contract for and in many bear the risk for the cost of healthcare services received by a group.

Value

Focusing on both quality and cost at the same time in purchasing and delivering healthcare.

What three components do value-based purchasing (VBP) systems and pay-for-performance (P4P) systems typically link?

Quality, performance, and payment

What three reports provided the impetus for VBP/P4P systems?

To Err Is Human Crossing the quality chasm Rewarding Provider Performance

VBP/P4P systems only include financial rewards.

a. True
b. False

b. False

VBP/P4P systems have been slow in getting established since 2004.

a. True
b. False

b. False

What are two major categories of VBP/P4P models?

Reward-based models and penalty-based models

What targets should be the focus of VBP/P4P systems?

Most significant problems in terms of quality or cost, proportion of population covered by the service or provider, and availability of valid and reliable performance measures.

The very first pay-for-performance systems emerged in the early 1990s.

a. True
b. False

b. False

What is attribution and by what other terms is this process known?

Attribution is the determination of who rendered care so that the care’s outcomes can be linked to its provider and that provider receives the reward or penalty. Other terms for attribution are enrollee assignment or beneficiary assignment.

The Centers for Medicare and Medicaid Services has attempted to ‘brake’ the pay-for-performance and value-based purchasing systems trend because its experts believe the linkage of quality and rewards jeopardizes the care of patients

a. True
b. False

b. False

List three other countries that are investigating or have implemented pay-for-performance systems for their healthcare delivery systems.

Australia, Canada, Great Britain

Withholding compensation would be considered a penalty-based model of pay-for-performance.

a. True
b. False

a. True

What piece of legislation mandated CMS to develop a value-based purchasing system?

Deficit Reduction Act of 2005

What type of VBP program is the Hospital Acquired Conditions Reduction Program?

Paying for Value.

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