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 |
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 |
a. major |
In Prospective payment method the payment is ____ before the services are rendered. a. preset |
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 |
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 |
Under MSDRGs, all of the following factors influence a facility’s case mix index, except: a. The productivity standard for coders |
a. The productivity standard for coders |
Which of the following is not a reason to perform case-mix a. Analyze reimbursement fluctuations |
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 |
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 |
Which governmental fraud and abuse effort focused on recouping lost funds for the Medicare Program due to inaccurate coding and billing? ($188 million were a. Hospital Payment Monitoring Program |
c. Operation Restore Trust |
The policies and procedures section of a Coding Compliance Plan should include: a. Physician query process |
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 |
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 |
d. All of the above |
All of the following entities are voluntary healthcare insurance except: a. Private healthcare insurance plans |
c. Medicare |
Which of the following entities is also known as a "group plan?" a. Private individual healthcare insurance plan |
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 |
c. Individual |
From figure, determine the insured: a. 123456 7890 |
d. JANE B. WHITE |
What third-party payer does the figure represent? a. Medicaid |
d. Commercial healthcare insurance |
Which of the following characteristics is the greatest advantage of group healthcare insurance? a. More stringent preexisting condition restrictions |
c. Greater benefits for lower premiums |
Which of the following characteristics is representative of commercial healthcare insurances? a. National federation of forty independent, locally |
c. For-profit in the private sector |
In regards to healthcare insurance, the percentage that the guarantor pays is called the: a. Co-payment |
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 |
a. Estimates the proportions of the payments from the primary and secondary carriers |
All of the following are cost-sharing provisions except: a. Benefit |
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 |
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 |
Codes and Remarks What does figure 4 represent? a. Explanation of benefits |
a. Explanation of benefits |
Codes and Remarks Had the subscriber met the deductible prior to the service? a. Yes, as evidenced by the plan’s $250 payment for the |
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 |
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 |
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) |
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 |
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 |
d. B and C |
Which of the following is/are true of CHIP? a. It is a federal/state program |
d. A and C are true |
The Medicare Program is divided into _____ parts. a. 2 |
c. 4 |
Medicare part C is a ___________ option known as Medicare Advantage a. Managed care |
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. |
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 |
a. TRICARE Prime |
In which type of HMO are the physicians employees? a. Group model |
c. Staff model |
What is the term for an explicit statement that directs clinical decision making? a. Cookbook medicine |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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. |
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 |
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 |
The MS-DRG payment includes reimbursement for all of the following inpatient services <b>except</b>: a. Medications |
b. Progress notes |
Select the highest level of the IPPS hierarchy: a. Multiple significant trauma |
d. Major diagnostic category |
What is the general term for software that assigns inpatient diagnosis related groups? a. Encoder |
b. Grouper |
What is Medicare’s term for a facility with a high percentage of low-income patients? a. Disproportionate share hospital |
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 |
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 |
In MS-DRGs, for what is the case-mix index a proxy? a. Risk of mortality |
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 |
a. Base payment rate |
Which reimbursement scheme is used in the Inpatient Psychiatric Facility Prospective Payment System? a. Case rate |
d. Per diem rate |
Under the IPF PPS which states are included in the cost of living adjustment (COLA)? a. Alaska and Hawaii |
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 |
Which Congressional act called for the creation of a PPS for the psychiatric inpatient setting? a. Omnibus Consolidated and Emergency Supplemental |
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 |
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 |
True |
True or false: The MS-DRG system is a refinement of the DRG system, which used major complications/comorbidity (MCC) diagnosis codes and |
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 a. Conversion factor |
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 |
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 |
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 |
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 |
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% |
c. 20% |
CMS assigns one____________to each APC and each ___________code. a. payment status indicator, HCPCS |
a. payment status indicator, HCPCS |
These are assigned to every HCPCS/CPT code under the Medicare HOPPS to identify how the service or procedure a. geographic practice cost indices |
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 |
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 |
d. Radiation therapy |
Which classification system is used to case-mix adjust the SNF payment rate? a. IRVEN |
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 |
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 |
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 |
a. Home health agency |
Generally, what is the average length of stay of long-term a. >15 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 |
Patients with all the following conditions are appropriate for LTCHs <b>except</b>: a. Chronic tuberculosis |
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 |
In the LTCH PPS, what is the standard federal rate? a. Constant that converts the MS-LTC-DRG weight into a payment |
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 |
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 |
a. Brain injury |
All of the following elements are part of the IRF PPS <b>except</b>: a. Major diagnostic category |
a. Major diagnostic category |
All of the following types of diagnoses are used in the IRF a. Principal |
a. Principal |
In the IRF PPS, what is the tool for data collection that drives payment: a. Medicare Provider Analysis Review |
d. Patient assessment instrument |
What data set provides the underpinning of the HHPPS? a. UHDDS |
c. OASIS |
All of the following services are consolidated into a single payment under the HHPPS <b>except</b>: a. Home health aide visits |
c. durable medical equipment |
All of the following domains are part of the HHPPS case mix <b>except</b>: a. Clinical severity |
d. Medical malpractice |
How many HHRGs are there? a. 80 |
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 |
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 |
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 |
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 |
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 |
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 |
d. Collected |
Most facilities begin counting days in accounts receivable at which of the following times? a. The date the patient registers |
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 |
a. Dollars in accounts receivable |
The dollar amount the facility actually bills for the services it provides is known as: a. Cost |
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 |
a. Explanation of Benefits |
Statement that describes services rendered, payment a. Explanation of Benefits |
b. Medicare Summary Notice |
Report sent by third-party payer that outlines claim a. Explanation of Benefits |
c. Remittance Advice |
Waiver signed by the patient acknowledging that because a. Explanation of Benefits |
d. ABN |
Intermediaries reimburse inpatient or hospital services a. FI |
a. FI |
Newly established contracting authority to administer a. FI |
b. MAC |
Database used by healthcare facilities to house the price list a. FI |
c. CDM |
Key performance indicator a. FI |
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 |
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 |
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 |
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 |
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 |
Determine the possible result and risk area of this CDM issue. Undercharging for services a. Overpayment/compliance |
c. Underpayment/lost revenue |
Determine the possible result and risk area of this CDM issue. Nonspecific or inaccurate HCPCS procedure codes a. Overpayment/compliance |
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 |
False |
True or false: Pay-for-performance |
False |
What are the two major categories of pay-for-performance |
Reward-based Penalty-based |
What targets should be the focus of pay-for-performance |
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 |
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 |
HIM 2430 — Principles of Healthcare Reimbursement FINAL
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