HIM 2430 — Principles of Healthcare Reimbursement FINAL

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True or False: A group of insureds with similar risks or loss is known as a risk pool.

True

Reimbursement for healthcare depends on patients having _______?

health insurance

True or false: The premiums received by the insurance company do not offset the loss the insurance company assumes.

False. Insurance premiums do offset the loss the insurance company assumes.

True or false: Health insurance became established in 1929 when Blue Cross covered schoolteachers in Texas.

True

In which type of payment method does the payer learn of the costs for health services after the services are performed?

a. prospective payment system
b. retrospective payment system
c. APC
d. RVRBS

b. retrospective payment system

True or false: Dependent coverage is for spouses and children.

True

True or false: Health insurance that covers only the employee is known as individual coverage.

True

Episode-of-care and Fee-for-service reimbursements are ____types of unit of payments.

a. major
b. minor
c. retrospective

a. major

In Prospective payment method the payment is ____ before the services are rendered.

a. preset
b. not determined

a. preset

When was the Medicare pharmacy benefit plan (e.g., Medicare Part D) implemented ?

2006

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

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

b. ICD-10-CM

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

Under MSDRGs, all of the following factors influence a facility’s case mix index, except:

a. The productivity standard for coders
b. Changes in services offered by the facility
c. Changes made by CMS to MS-DRG relative weights
d. Accuracy of documentation and coding

a. The productivity standard for coders

Which of the following is not a reason to perform case-mix
analysis?

a. Analyze reimbursement fluctuations
b. Determine the correct MS-DRG assignment for an
encounter
c. Describe a population to be served
d. Identify differences in practice patterns or coding
complexity

b. 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?

a. Makes it lower than warranted by the actual service/resource intensity of the facility
b. Makes it higher than warranted by the actual
service/resource intensity of the facility
c. Does not affect the hospital’s MS-DRG case mix
d. Coding has nothing to do with a hospital’s MS-DRG
case mix

a. 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?

a. 1234A
b. A1234
c. 123A4
d. 12A34

b. A1234

Which governmental fraud and abuse effort focused on recouping lost funds for the Medicare Program due to inaccurate coding and billing? ($188 million were
recovered during the first two years of this effort.)

a. Hospital Payment Monitoring Program
b. OIG Compliance Program Guidance
c. Operation Restore Trust
d. Medicare Integrity Program

c. Operation Restore Trust

The policies and procedures section of a Coding Compliance Plan should include:

a. Physician query process
b. Unbundling
c. Assignment of discharge destination codes
d. All of the above

d. All of the above

MS-DRG relationships comparing with MCC or CC to without MCC/CC MS-DRGs for the same clinical condition should be reviewed because:

a. MCC/CCs can be overcoded by coders
b. MCC/CCs can be undercoded by coders
c. Both a and b are correct
d. MCC/CCs should not be reported by coders

c. Both a and b are correct

Recovery Audit Contractors are different from other improper payment review contractors because:

a. RACs audit inpatient and outpatient claims
b. RACs are charged with finding overpayment and
underpayments
c. RACs are reimbursed on a contingency-based
system
d. All of the above

d. All of the above

All of the following entities are voluntary healthcare insurance except:

a. Private healthcare insurance plans
b. Commercial healthcare insurance plans
c. Medicare
d. Blue Cross and Blue Shield

c. Medicare

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

a. Private individual healthcare insurance plan
b. Blue Cross and Blue Shield
c. Employer-based healthcare insurance plan
d. Medicare

c. Employer-based healthcare insurance plan

From figure, determine whether the plan covers Gill F. White, Jane’s spouse.

No, the card states "Employee-Only"

According to figure, what type of coverage does the third-party payer provide Jane B. White?

a. Family
b. Dependent
c. Individual
d. Premiere

c. Individual

From figure, determine the insured:

a. 123456 7890
b. STATE
c. ABC Premiere Health Plan
d. JANE B. WHITE

d. JANE B. WHITE

What third-party payer does the figure represent?

a. Medicaid
b. Medicare
c. Blue Cross and Blue Shield
d. Commercial healthcare insurance

d. Commercial healthcare insurance

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

a. More stringent preexisting condition restrictions
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 characteristics is representative of commercial healthcare insurances?

a. National federation of forty independent, locally
operated plans
b. Composed of geographic plans and the FEP
c. For-profit in the private sector
d. Account for about one-fourth of US healthcare
expenditures

c. For-profit in the private sector

In regards to healthcare insurance, the percentage that the guarantor pays is called the:

a. Co-payment
b. Deductible
c. Coinsurance
d. Contractual disallowance

c. Coinsurance

The insurance analyst at the large group practice is responsible for issues related to coordination of benefits. What does he or she do?

a. Estimates the proportions of the payments from the primary and secondary carriers
b. Arranges the healthcare for a patient across the continuum of care
c. Reconciles discrepancies between the explanation of benefits and the claim
d. Examines the exclusions and the clauses of preexisting
conditions and wait periods of the patients’ policies

a. Estimates the proportions of the payments from the primary and secondary carriers

All of the following are cost-sharing provisions except:

a. Benefit
b. Formulary
c. Copayment
d. Limitation

a. Benefit

The child’s prescription drug is not on the healthcare plan’s formulary. The pharmacist states that the drug’s cost is $113.45. Per figure 2, how much should the guarantor expect to pay for the prescription?

a. $10
b. $40
c. $113.45
d. Cannot be determined

b. $40

Use the information in figure 3 to answer the following question. New employee Jan Smith had worked for a manufacturing firm. While working for the manufacturing firm, she was covered under its group healthcare insurance for 8 months. Jan terminated her employment with the manufacturing firm on a Friday and began a new position with a computer vendor the following Monday. The computer vendor also offers its employees a group healthcare plan. What is the maximum waiting period Jan should expect for her preexisting condition?

a. 63 days
b. 4 months
c. 12 months
d. Cannot be predicted

b. 4 months

Codes and Remarks
CI Coinsurance
CP Copayment
DD Deductible

What does figure 4 represent?

a. Explanation of benefits
b. Insurance coverage advanced notice service waiver
c. Insurance claim form
d. Encounter form

a. Explanation of benefits

Codes and Remarks
CI Coinsurance
CP Copayment
DD Deductible

Had the subscriber met the deductible prior to the service?

a. Yes, as evidenced by the plan’s $250 payment for the
deductible
b. Yes, as evidenced by the application of the copayment
provision
c. No, as evidenced by the guarantor’s payment of $250
d. Cannot be determined

c. No, as evidenced by the guarantor’s payment of $250

Which Part of the Medicare program was created under the Medicare Modernization Act of 2003 (MMA)?

a. Part A
b. Part B
c. Part C
d. Part D

d. Part D

This program, formerly CHAMPUS (Civilian Health and Medical Program – Uniformed Services), provides coverage for the dependents of active members of the armed forces.

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

a. TRICARE

Which government-sponsored program replaced the Aid to Families with Dependent Children (AFDC) program in 1996?

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

a. Temporary Assistance for Needy Families program (TANF)

Which of the following is <b>not</b> 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

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. B and C

d. B and C

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

d. A and C are true

The Medicare Program is divided into _____ parts.

a. 2
b. 3
c. 4
d. 5

c. 4

Medicare part C is a ___________ option known as Medicare Advantage

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

a. Managed care

All of the following are true of state Medicaid programs <b>except</b>:

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. Services offered to beneficiaries are the same in each state.
d. States may offer a managed care option.

c. 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?

a. TRICARE Prime
b. TRICARE Standard
c. TRICARE for Life
d. All of the above

a. TRICARE Prime

In which type of HMO are the physicians employees?

a. Group model
b. Independent practice association (IPA) model
c. Staff model
d. Network model

c. Staff model

What is the term for an explicit statement that directs clinical decision making?

a. Cookbook medicine
b. Preauthorization
c. Evidence-based practice guideline
d. Withhold pool

c. Evidence-based practice guideline

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

a. To encourage the delivery of affordable, quality healthcare
b. To increase the number of physicians in primary care
c. To deter the privatization of the Blue Cross plans
d. To standardize the costs of healthcare across the nation

a. To encourage the delivery of affordable, quality healthcare

All of the following are characteristics of managed care organizations <b>except</b>:

a. Coordination of care across the continuum
b. Integration of financing and delivery of health
c. Management of costs and outcomes
d. Freedom of choice and autonomous decision making

d. Freedom of choice and autonomous decision making

All of the following are purposes of the surveys that managed care organizations send their patient/members <b>except</b>:

a. Reasons for referral to specialists
b. Perceptions of the plans’ strengths and weaknesses
c. Suggestions for improvements
d. Intentions regarding reenrollment

a. Reasons for referral to specialists

What is the term that means evaluating, for a healthcare service, the appropriateness of its setting and its level of service?

a. Coordination of service benefits
b. Community rating
c. Outcomes assessment
d. Utilization review

d. Utilization review

All of the following sets represent criteria for medical necessity and utilization review <b>except</b>:

a. Intensity of Service, Severity of Illness, and Discharge
Screens
b. Appropriateness Evaluation Protocol
c. Milliman and Robertson Guidelines
d. Federal Register Index and Ratings

d. Federal Register Index and Ratings

Gatekeepers determine the appropriateness of all of the following components <b>except</b>:

a. Rate of capitation or reimbursement
b. Healthcare service itself
c. Level of healthcare personnel
d. Setting in the continuum of care

a. 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?

a. Social security
b. Drug enforcement administration
c. Credit score
d. Precertification

d. Precertification

For which one of the following healthcare services is the managed care plan <b>least likely</b> to require a second opinion?

a. Procedures that are high cost
b. Conditions for which the diagnostic evidence is
equivocal
c. Treatment protocols that have low risk
d. Treatments for which experts’ opinions differ on
efficacy

c. Treatment protocols that have low risk

In the 1970s, what factors affected the Medicare Program?

a. The increase in Medicare expenditures for inpatient hospital care jeopardized Medicare’s ability to fund other health programs.
b. Deductibles had remained stagnant, generating insufficient income
c. Increased incomes of US citizens and, concomitantly, their increased payroll deductions paid into the Medicare
Program assured its financial solvency
d. The clear and succinct cost-based reporting requirements generated enthusiasm for the Medicare Program in the provider community.

a. 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 prospective payment system?

a. Incentive for cost control because hospitals retain profits or suffer losses based on differences between payment rate and actual costs
b. Retrospective, charge-based payment
c. Directly tied to past or current actual charges
d. Partial payments with add-ons for severity of illness

a. 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?

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

b. Case mix index

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

a. Medications
b. Progress notes
c. Laboratory tests
d. Dressings and other supplies

b. Progress notes

Select the highest level of the IPPS hierarchy:

a. Multiple significant trauma
b. Surgical section
c. Diagnosis related group
d. Major diagnostic category

d. Major diagnostic category

What is the general term for software that assigns inpatient diagnosis related groups?

a. Encoder
b. Grouper
c. Aligner
d. Scrubber

b. Grouper

What is Medicare’s term for a facility with a high percentage of low-income patients?

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

a. Disproportionate share hospital

What condition does CMS require be met for a facility to receive the indirect medical education adjustment?

a. Medical residents in an approved graduate medical education program
b. Medical residents and nurses in approved educational
programs
c. Medical residents, nurses, and allied health personnel in
approved educational programs
d. Any type of health personnel in training including the above listed types as well as other types, such as medical social workers, pharmacists, dentists, recreational and music therapists, and child and family development specialists

a. Medical residents in an approved graduate medical education program

What is the name of the entity that pays Medicare Part A claims?

a. Pricer
b. Medicare Administrative Contractor
c. CMS
d. Medicare Code Editor

b. Medicare Administrative Contractor

In MS-DRGs, for what is the case-mix index a proxy?

a. Risk of mortality
b. Difficulty of treatment
c. Consumption of resources
d. Prognosis

c. Consumption of resources

In the IPPS, what is the term for each hospital’s unique standardized amount based on its costs per Medicare discharge?

a. Base payment rate
b. Diagnosis related group
c. Carrier amount
d. Cost outlier

a. Base payment rate

Which reimbursement scheme is used in the Inpatient Psychiatric Facility Prospective Payment System?

a. Case rate
b. Retrospective cost based
c. Case rate with exclusions
d. Per diem rate

d. Per diem rate

Under the IPF PPS which states are included in the cost of living adjustment (COLA)?

a. Alaska and Hawaii
b. California and Alaska
c. California and Hawaii
d. Hawaii and New York

a. Alaska and Hawaii

Medicare inpatient reimbursement levels are based on:

a. CPT codes reported during the encounter
b. MS-DRG calculated for the encounter
c. Charges accumulated during the episode of care
d. Usual and customary charges reported during the
encounter

b. MS-DRG calculated for the encounter

Which Congressional act called for the creation of a PPS for the psychiatric inpatient setting?

a. Omnibus Consolidated and Emergency Supplemental
Appropriations Act of 1999
b. Medicare, Medicaid and SCHIP Benefits Improvement Act of 2000
c. Balanced Budget Act of 1997
d. Balanced Budget Refinement Act of 1999

d. Balanced Budget Refinement Act of 1999

True or false: Reform in the federal method of reimbursing providers for healthcare services resulted from three trend.

a. Rising healthcare payments using the funds in the Medicare Trust at a rate faster than US workers were contributing dollars
2. Fraud and abuse in the system, which wasted funding
3. Payment rules that were not uniformly applied across the nation

True

True or false: The IPPS is the Medicare reimbursement system for inpatient services provided in an acute care setting.

True

True or false: The Federal Register is the official journal of the US government

True

True or false: Each year, for the federal payment system, CMS published proposed rules and final rules in the Federal Register

True

True or false: Each DRG is assigned a relative weight (RW) that is intended to represent the resource intensity of the clinical group.

True

True or false: Each DRG should contain patient’s of varying patterns of resource intensity.

False

True or false: Multiple DRGs can be assigned and reimbursed for a single admission.

False

True or false: Physician services are included in the DRG reimbursement to the hospital.

False. Physicians are reimbursed under the resource-based relative value scales (RBRVS) and not included in the DRG reimbursement.

True or false: The DRG system is a hierarchical in design, the highest level in the hierarchy is Major Diagnostic Categories (MDCs) represent the body systems treated by
medicine.

True

True or false: The MS-DRG system is a refinement of the DRG system, which used major complications/comorbidity (MCC) diagnosis codes and
complication/comorbidity (CC) diagnosis codes to establish a greater number of classifications or MSDRGs.

True

It is the year 2013, the federal government is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government
reduce?

a. Conversion factor
b. RVU
c. GPCI
d. Weighted Discount

a. Conversion factor

Which element of the RVU accounts for the costs of the medical practice, such as office rent, wages of non-physician personnel, and supplies and equipment?

a. Work value
b. Malpractice expenses
c. Extent of the physical exam
d. Practice expenses

d. Practice expenses

Which of the following status indicators indicates that the APC payment is reduced when multiple procedures with this status are reported together?

a. V medical visit
b. X ancillary service
c. T = surgical service
d. S = significant procedure
e. G pass-through drug

c. T = surgical service

The prospective payment system used by hospitals for the majority of services provided to Medicare hospital outpatients is called __________and became effective on_______.

a. Laboratory Fee Schedule, October 1, 2000
b. Ambulatory Patient Groups, January 1, 2000
c. Ambulatory Payment Classifications, August 1, 2000
d. Medicare Fee Schedule, August 1, 2000

c. Ambulatory Payment Classifications, August 1, 2000

Which of the following statements is <b>true</b> about APCs?

a. APCs are based solely on the patient’s principal diagnosis
b. ICD-9-CM procedure codes are used to group patients
c.Severity of illness is taken into consideration when grouping APCs
d. APCs are based on the CPT or HCPCS code(s) reported

d. APCs are based on the CPT or HCPCS code(s) reported

True or false: Procedures in HOPPS with a status indicator of <b>V</b> are indicated as inpatient only; they must be provided to Medicare beneficiaries in an inpatient setting and are reimbursed under the IPPS.

False. Status indicator C denotes inpatient only.

Under APCs, the patient is responsible for paying the coinsurance amount based upon______of the national median charge for the services rendered.

a. 50%
b. 15%
c. 20%
d. 80%

c. 20%

CMS assigns one____________to each APC and each ___________code.

a. payment status indicator, HCPCS
b. CPT code, HCPCS
c. MSDRG,
CPT
d. payment status indicator, ICD9CM

a. payment status indicator, HCPCS

These are assigned to every HCPCS/CPT code under the Medicare HOPPS to identify how the service or procedure
described by the code would be paid.

a. geographic practice cost indices
b. major diagnostic categories
c. minimum data set
d. payment status indicator

d. payment status indicator

Which of the following best describes the situation of a provider who agrees to accept assignment for Medicare Part B services?

a. The provider is reimbursed at 15% above the allowed charge
b. The provider is paid according to the Medicare Physician Fee Schedule plus 10%
c. The provider cannot bill the patients for the balance between the MPFS amount and the total charges
d. The provider is a nonparticipating provider.

c. The provider cannot bill the patients for the balance between the MPFS amount and the total charges

Under the SNF PPS, which one of the following healthcare services is excluded from the consolidated payment?

a. Laboratory tests
b. Routine care
c. Medications
d. Radiation therapy

d. Radiation therapy

Which classification system is used to case-mix adjust the SNF payment rate?

a. IRVEN
b. Geographic cost index
c. Resource utilization groups
d. Wage index

c. Resource utilization groups

In the SNF PPS, which data set determines a resident’s classification into a resource utilization group?

a. Medicare Provider Analysis Review
b. Uniform Hospital Discharge Data Set
c. Activities of Daily Living
d. Minimum Data Set

d. Minimum Data Set

In the PAC payment systems, which tool does CMS use to adjust its payment rates to account for geographic variations in costs?

a. National episode amount
b. Neutrality adjuster
c. Market basket
d. cost reports

c. Market basket

In which of the PAC payment systems, is the unit of payment the 60-day episode of care?

a. Home health agency
b. Long term care hospital
c. Inpatient rehabilitation facility
d. Skilled nursing facility

a. Home health agency

Generally, what is the average length of stay of long-term
care hospitals?

a. &gt;15 days
b. &gt;25 days
c. &gt;30 days
d. &gt;60 days

b. >25 days

In terms of their composition, how do the groups of the MS-LTC-DRGs compare to the groups of the acute care MS-DRGs?

a. Fewer groups with wider range of conditions in each
b. Exactly the same
c. Fewer groups with wider range of conditions in each
d. None of the above

b. Exactly the same

Patients with all the following conditions are appropriate for LTCHs <b>except</b>:

a. Chronic tuberculosis
b. Sequelae of head trauma
c. Ventilator-dependent emphysema
d. Acute myocardial infarction

d. Acute myocardial infarction

In terms of grouping and reimbursement, how are the MS-LTC-DRGs and acute care MS-DRGs similar?

a. Relative weights
b. Based on principal diagnosis
c. Categorization of low volume groups into quintiles
d. Classification of short-stay outliers

b. Based on principal diagnosis

In the LTCH PPS, what is the standard federal rate?

a. Constant that converts the MS-LTC-DRG weight into a payment
b. Relative weight based on the market basket of goods
c. Geographic wage index
d. Adjustment mandated by the Benefits Improvement
and Protection Act (BIPA) of 2000

a. Constant that converts the MS-LTC-DRG weight into a payment

According to the CMS, what is one of the purposes of the IRF PPS?

a. To promote equity for beneficiaries, facilities, and taxpayers
b. To increase the number of inpatient rehabilitation beds
in the U.S.
c. Both a and b
d. None of the above

a. To promote equity for beneficiaries, facilities, and taxpayers

To meet the definition of an IRF, facilities must have an inpatient population with at least a specified percentage of patients with certain conditions. Which of the following conditions is counted in the definition?

a. Brain injury
b. Chronic myelogenous leukemia
c. Acute myocardial infarction
d. Cancer

a. Brain injury

All of the following elements are part of the IRF PPS <b>except</b>:

a. Major diagnostic category
b. Impairment group code
c. Rehabilitation impairment category
d. Patient assessment instrument

a. Major diagnostic category

All of the following types of diagnoses are used in the IRF
PPS <b>except</b>:

a. Principal
b. Admitting
c. Etiologic
d. Complication or co-morbidity

a. Principal

In the IRF PPS, what is the tool for data collection that drives payment:

a. Medicare Provider Analysis Review
b. Inpatient Rehabilitation Validation and Entry
c. Activities of Daily Living
d. Patient assessment instrument

d. Patient assessment instrument

What data set provides the underpinning of the HHPPS?

a. UHDDS
b. MHDS
c. OASIS
d. HAVEN

c. OASIS

All of the following services are consolidated into a single payment under the HHPPS <b>except</b>:

a. Home health aide visits
b. Routine and non-routine medical supplies
c. durable medical equipment
d. Nursing and therapy services

c. durable medical equipment

All of the following domains are part of the HHPPS case mix <b>except</b>:

a. Clinical severity
b. Functional status
c. Service utilization
d. Medical malpractice

d. Medical malpractice

How many HHRGs are there?

a. 80
b. 153
c. 510
d. 945

b. 153

What is the term used in a rehabilitation facility to mean "a patient’s ability to perform activities of daily living?"

a. compliance threshold
b. etiologic diagnosis
c. functional status
d. normalization

c. functional status

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?

a. Skilled nursing facility
b. Long term care hospital
c. Inpatient rehabilitation facility
d. Home health agency

a. Skilled nursing facility

Which of the following is the definition of revenue cycle management?

a. The regularly repeating set of events that produces revenue or income
b. The method by which patients are grouped together based on a set of characteristics
c. The systematic comparison of the products, services, and outcomes of one organization with those of a similar
organization
d. Coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue

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

The term "soft coding" refers to:

a. CPT codes that are coded by the coders
b. CPT codes that appear in the hospital’s charge master
c. ICD-9-CM codes that are coded by the coders
d. ICD-9-CM codes that appear in the hospital’s
charge master

a. CPT codes that are coded by the coders

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?

a. Dollars billed
b. Aging of accounts
c. Accounts Receivable
d. Cash balance

c. Accounts Receivable

Healthcare facilities should think of the collection process as part of the complete billing process and should educate staff to the fact that not all money billed is ____?

a. Pending
b. Charged
c. Reimbursable
d. Collected

d. Collected

Most facilities begin counting days in accounts receivable at which of the following times?

a. The date the patient registers
b. The date the patient is discharged
c. The date the bill drops
d. The date the bill is received by the payer

c. The date the bill drops

The amount of money owed a healthcare facility when claims are pending is called ____:

a. Dollars in accounts receivable
b. Bad debt
c. The write-off account
d. Delayed revenue

a. Dollars in accounts receivable

The dollar amount the facility actually bills for the services it provides is known as:

a. Cost
b. Charge
c. Reimbursement
d. Contractual allowance

b. Charge

Report sent from a healthcare insurer to the policyholder and to the provider that describes the healthcare service, its cost, applicable cost-sharing, and the amount the healthcare insurer will cover.

a. Explanation of Benefits
b. Medicare Summary Notice
c. Remittance Advice
d. ABN

a. Explanation of Benefits

Statement that describes services rendered, payment
covered, and benefits limits and denials for Medicare
beneficiaries

a. Explanation of Benefits
b. Medicare Summary Notice
c. Remittance Advice
d. ABN

b. Medicare Summary Notice

Report sent by third-party payer that outlines claim
rejections, denials, and payments to the facility.

a. Explanation of Benefits
b. Medicare Summary Notice
c. Remittance Advice
d. ABN

c. Remittance Advice

Waiver signed by the patient acknowledging that because
medical necessity for a procedure, service, or supply
cannot be established, the patient accepts responsibility
for reimbursing the provider or DME-POS dealer for costs
associated with the procedure, service, or supply.

a. Explanation of Benefits
b. Medicare Summary Notice
c. Remittance Advice
d. ABN

d. ABN

Intermediaries reimburse inpatient or hospital services
(Part A Medicare) and some Part B services. Contract with
CMS to act as agents of the federal government in dealing
with participating providers of Medicare.

a. FI
b. MAC
c. CDM
d. Discharged not final billed report

a. FI

Newly established contracting authority to administer
Medicare Part A and Part B as required by the MMA of 2003.

a. FI
b. MAC
c. CDM
d. Discharged not final billed report

b. MAC

Database used by healthcare facilities to house the price list

a. FI
b. MAC
c. CDM
d. Discharged not final billed report

c. CDM

Key performance indicator

a. FI
b. MAC
c. CDM
d. Discharged not final billed report

d. Discharged not final billed report

True or false: The 21st-century approach to RCM in healthcare is based on a silo approach in which each clinical department is responsible for its own functions
and contributions to the revenue cycle.

False. RCM is based on a multidisciplinary model.

The basic CDM model maintained by the facility contains the all the following <b>except</b>:

a. Price/charge for services/procedures
b. Revenue Code
c. General ledger key
d. HCPCS code with service description
e. Status indicator

e. Status indicator

The final rule known as the Standards for Electronic Transactions and Code Sets or Transactions Rule, identified eight electronic transactions and six code
sets. What are they?

Heatlh Care Financing Administration Common Procedure Coding System ICD-9-CM, Volumes 1 and 2 ICD-9-CM Volume 3 National Drug Codes CPT, 4th Edition Code on Dental Procedures

Determine the possible result and risk area of this CDM issue.

Overcharging for services

a. Overpayment/compliance
b. Claims rejection/denial
c. Underpayment/lost revenue
d. Claims rejection/denial/lost revenue

a. Overpayment/compliance

Determine the possible result and risk area of this CDM issue.

Inaccurate revenue code assignment

a. Overpayment/compliance
b. Claims rejection/denial
c. Underpayment/lost revenue
d. Claims rejection/denial/lost revenue

b. Claims rejection/denial

Determine the possible result and risk area of this CDM issue.

Undercharging for services

a. Overpayment/compliance
b. Claims rejection/denial
c. Underpayment/lost revenue
d. Claims rejection/denial/lost revenue

c. Underpayment/lost revenue

Determine the possible result and risk area of this CDM issue.

Nonspecific or inaccurate HCPCS procedure codes

a. Overpayment/compliance
b. Claims rejection/denial
c. Underpayment/lost revenue
d. Claims rejection/denial/lost revenue

d. Claims rejection/denial/lost revenue

What two reports provided the impetus for pay-for-performance and value-based purchasing systems?

Crossing the Quality Chasm 2001 Rewarding Provider Performance: Aligning Incentives in Medicare 2007

What three components do VBP and P4P systems typically link?

Cost, setting, and duration. FEEDBACK: Quality, performance, and reimbursement (or incentives or rewards)

True or false: Pay-for-performance and value-based
purchasing systems only include financial rewards.

False

True or false: Pay-for-performance
systems have been slow in getting established since 2004.

False

What are the two major categories of pay-for-performance
models?

Reward-based Penalty-based

What targets should be the focus of pay-for-performance
and value-based purchasing systems?

Meet the goals set by performance measures to improve the quality of patient care and lower costs. FEEDBACK: 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

What is the ramification for hospitals that do not participate or do not submit sufficient data under the Reporting of Hospital Quality Data for Annual Payment
Update (RHQDAPU) program?

Hospitals that do not participate or submit sufficient data are subject to a 2% reduction in their inpatient APU.

What criteria must be met for the Secretary of Health and Human Services to include a condition on the Hospital Acquired Conditions provision list?

The condition must be -High-cost,high-volume or both Result in the assignment of a case to a DRG with higher payment when present as a secondary diagnosis -Could reasonably have been prevented by applying evidence-based guidelines.

What are the ten categories initially monitored for the Hospital Acquired Condition provision of IPPS?

Catheter-associated urinary tract infection Pressure ulcers Serious preventable event—object left in surgery Serious preventable event—air embolism Serious preventable event—blood incompatibility Vascular catheter-associated infection Fall, fracture, dislocation, intracranial injury, crushing injury Burns, manifestations of poor glycemic control Surgical site infections Pulmonary embolism and deep vein thrombosis after certain orthopedic procedures

What are the two domains included in the Hospital Value-Based Purchasing Program?

Clinicial process of care Patient experience of care

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