Healthcare Reimbursement Final Exam Fall 2023 with
verified solutions
There are 3 parties in healthcare reimbursement. Who is the first party?
Patient or guarantor
Which type of reimbursement methodology is associated with the abbreviation
"PMPM"?
Capitated payment
What is an example of a charge that usually would be reviewed by an HIM coder?
Claim is failing due to potentially incomplete code, including missing modifiers.
Which of the following coding systems was created for reporting procedures and
services performed by physicians in clinical practice?
CPT
What impact does a hospital acquired condition have on a hospital's Medicare
reimbursement?
If a hospital acquired condition causes a case to be grouped to a higher paying DRG,
Medicare will only reimburse for the lower paying DRG.
In the healthcare insurance sector, what does UCR stand for?
Usual Customary and Reasonable
Which statement describes the per diem payment method?
Fixed rate for each day a covered member is hospitalized
Which discounted fee-for-service healthcare payment method does Medicare use
to reimburse physicians?
RBRVS
Which type of RAC review combines data analysis and submission of medical
records to the RAC?
Semi-automated
In the healthcare industry, what is the term for receiving compensation for
healthcare services that were previously provided?
Reimbursement
To which of the following factors is health insurance status most closely linked?
Employment
What is the optimum chart completion window for revenue cycle purposes?
Within the bill hold period
Which of the following is the correct format for HCPCS Level II codes?
A1234
In the United States, what is healthcare insurance?
Reduction of a person's or a group's exposure to risk for unknown healthcare costs by
the assumption of that risk by an entity
In the healthcare industry, what is another term for "fee"?
Charge
What is the purpose of a random audit of coded data? Select all that apply.
Quality monitoring
Which of the following entities does not perform improper payment reviews for
CMS?
,None of the above
QIO
CERT
RACs
MACs
Which of the following payment methods are global?
Correct All of the above
Answers:
Block grants
Surgical packages
Bundling
Correct All of the above
Which of the following is an example of fraud?
Billing for a service not furnished as represented on the claim
Which patient registration error can appropriately be corrected by HIM coders, if
permitted by policy and procedures?
Admission date
Which is an example of a practice that will most likely result in late charges?
Due to low volume, radiation oncology collects their charges and posts once a week.
True or False? 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.
True
You have reviewed the OIG work plan for the coming year and note several
coding issues that you want to make sure are accurately addressed by your
coders. What is your first plan of action?
Targeted review
Which national model for the delivery of healthcare services is financed by
general revenue funds from taxes?
National health service (Beveridge) model
Why do health insurers pool premium payments for all the insureds in a group
and use actuarial data to calculate the group's premiums?
To assure that the pool is large enough to pay losses of the entire group
Which of the following is not a common cause of improper payments?
Implementation of a documentation improvement program
Recovery Audit Contractors are different from other improper payment review
contractors because:
RACs are reimbursed on a contingency-based system
, In the accounting system of the physician office, the account is categorized as
"self-pay." How should the insurance analyst interpret this category?
The guarantor will pay the entire bill.
In which type of reimbursement methodology do healthcare insurance companies
determine payment to providers before the services have been delivered?
Prospective payment
There are 3 parties in healthcare reimbursement. Who is the third party?
Payer
True or False? Payers that use per-diem payment rates reimburse the provider a
fixed rate for each day a covered member is hospitalized
True
Where and when did health insurance become established in the United States?
Texas, 1929
The federal government funds significant portions of which groups' healthcare?
Correct All of the above
Answers:
Seniors, people with disabilities, and people with end-stage renal disease
Low-income persons on state Medicaid
Active-duty and retired military personnel and their families and veterans
Native Americans
A and C only
A, C, and D only
Correct All of the above
Which of the following phrases mean "per head"?
Per capita
In which type of reimbursement methodology does the health insurance company
have the greatest degree of risk?
Retrospective
The policies and procedures section of a Coding Compliance Plan should
include:
:
Correct All of the above
Answers:
Upcoding
Coding medical records without complete documentation
Correct use of encoding software
Correct All of the above
verified solutions
There are 3 parties in healthcare reimbursement. Who is the first party?
Patient or guarantor
Which type of reimbursement methodology is associated with the abbreviation
"PMPM"?
Capitated payment
What is an example of a charge that usually would be reviewed by an HIM coder?
Claim is failing due to potentially incomplete code, including missing modifiers.
Which of the following coding systems was created for reporting procedures and
services performed by physicians in clinical practice?
CPT
What impact does a hospital acquired condition have on a hospital's Medicare
reimbursement?
If a hospital acquired condition causes a case to be grouped to a higher paying DRG,
Medicare will only reimburse for the lower paying DRG.
In the healthcare insurance sector, what does UCR stand for?
Usual Customary and Reasonable
Which statement describes the per diem payment method?
Fixed rate for each day a covered member is hospitalized
Which discounted fee-for-service healthcare payment method does Medicare use
to reimburse physicians?
RBRVS
Which type of RAC review combines data analysis and submission of medical
records to the RAC?
Semi-automated
In the healthcare industry, what is the term for receiving compensation for
healthcare services that were previously provided?
Reimbursement
To which of the following factors is health insurance status most closely linked?
Employment
What is the optimum chart completion window for revenue cycle purposes?
Within the bill hold period
Which of the following is the correct format for HCPCS Level II codes?
A1234
In the United States, what is healthcare insurance?
Reduction of a person's or a group's exposure to risk for unknown healthcare costs by
the assumption of that risk by an entity
In the healthcare industry, what is another term for "fee"?
Charge
What is the purpose of a random audit of coded data? Select all that apply.
Quality monitoring
Which of the following entities does not perform improper payment reviews for
CMS?
,None of the above
QIO
CERT
RACs
MACs
Which of the following payment methods are global?
Correct All of the above
Answers:
Block grants
Surgical packages
Bundling
Correct All of the above
Which of the following is an example of fraud?
Billing for a service not furnished as represented on the claim
Which patient registration error can appropriately be corrected by HIM coders, if
permitted by policy and procedures?
Admission date
Which is an example of a practice that will most likely result in late charges?
Due to low volume, radiation oncology collects their charges and posts once a week.
True or False? 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.
True
You have reviewed the OIG work plan for the coming year and note several
coding issues that you want to make sure are accurately addressed by your
coders. What is your first plan of action?
Targeted review
Which national model for the delivery of healthcare services is financed by
general revenue funds from taxes?
National health service (Beveridge) model
Why do health insurers pool premium payments for all the insureds in a group
and use actuarial data to calculate the group's premiums?
To assure that the pool is large enough to pay losses of the entire group
Which of the following is not a common cause of improper payments?
Implementation of a documentation improvement program
Recovery Audit Contractors are different from other improper payment review
contractors because:
RACs are reimbursed on a contingency-based system
, In the accounting system of the physician office, the account is categorized as
"self-pay." How should the insurance analyst interpret this category?
The guarantor will pay the entire bill.
In which type of reimbursement methodology do healthcare insurance companies
determine payment to providers before the services have been delivered?
Prospective payment
There are 3 parties in healthcare reimbursement. Who is the third party?
Payer
True or False? Payers that use per-diem payment rates reimburse the provider a
fixed rate for each day a covered member is hospitalized
True
Where and when did health insurance become established in the United States?
Texas, 1929
The federal government funds significant portions of which groups' healthcare?
Correct All of the above
Answers:
Seniors, people with disabilities, and people with end-stage renal disease
Low-income persons on state Medicaid
Active-duty and retired military personnel and their families and veterans
Native Americans
A and C only
A, C, and D only
Correct All of the above
Which of the following phrases mean "per head"?
Per capita
In which type of reimbursement methodology does the health insurance company
have the greatest degree of risk?
Retrospective
The policies and procedures section of a Coding Compliance Plan should
include:
:
Correct All of the above
Answers:
Upcoding
Coding medical records without complete documentation
Correct use of encoding software
Correct All of the above
