Chapter 4 Healthcare Reimbursement
Methodologies Study Questions and
Correct Answers
What is the difference between retrospective and prospective reimbursement?
✅Retrospective reimbursement is based on the actual resources expended to deliver
the services and is finalized after the services are delivered. Prospective reimbursement
is established prior to the healthcare delivery and does not change based on the costs
of the actual services delivered to the patient.
There are four guiding principles of prospective payment: ✅1. Payment rates are to be
established in advance and fixed for the fiscal period to which they apply.
2. Payment rates are not automatically determined by the hospital's past or current
actual cost.
3. Prospective payment rates are payment in full.
4. The hospital retains the profit or suffers a loss resulting from the difference between
the payment rate and the hospital's cost, creating an incentive for cost control.
Which of the following is not a type of retrospective reimbursement?
a. Global payment
b. Per diem
c. Fee schedule
d. Percent of billed charges ✅a. Global payment
Why is the fee schedule reimbursement methodology retrospective instead of
prospective? ✅Even though the reimbursement amount for each service is established
in advance, the type and number of services is unknown until after the services are
delivered.
Explain how bundled payment methodology differs from the case-rate methodology.
✅Case rate is provided to one provider for one admission or encounter. Bundled
payment is for multiple services provided by multiple provides over a set period of time,
which may include numerous encounters and admissions.
There are three essential characteristics of ACOs: ✅1. Ability to manage patients
across the continuum of care, including acute, ambulatory, and post-acute-care health
services
2. Capability to prospectively plan budgets and resource needs
3. Sufficient size to support comprehensive, valid, and reliable measurement of
performance (Devers and Berenson 2009, 2)
Methodologies Study Questions and
Correct Answers
What is the difference between retrospective and prospective reimbursement?
✅Retrospective reimbursement is based on the actual resources expended to deliver
the services and is finalized after the services are delivered. Prospective reimbursement
is established prior to the healthcare delivery and does not change based on the costs
of the actual services delivered to the patient.
There are four guiding principles of prospective payment: ✅1. Payment rates are to be
established in advance and fixed for the fiscal period to which they apply.
2. Payment rates are not automatically determined by the hospital's past or current
actual cost.
3. Prospective payment rates are payment in full.
4. The hospital retains the profit or suffers a loss resulting from the difference between
the payment rate and the hospital's cost, creating an incentive for cost control.
Which of the following is not a type of retrospective reimbursement?
a. Global payment
b. Per diem
c. Fee schedule
d. Percent of billed charges ✅a. Global payment
Why is the fee schedule reimbursement methodology retrospective instead of
prospective? ✅Even though the reimbursement amount for each service is established
in advance, the type and number of services is unknown until after the services are
delivered.
Explain how bundled payment methodology differs from the case-rate methodology.
✅Case rate is provided to one provider for one admission or encounter. Bundled
payment is for multiple services provided by multiple provides over a set period of time,
which may include numerous encounters and admissions.
There are three essential characteristics of ACOs: ✅1. Ability to manage patients
across the continuum of care, including acute, ambulatory, and post-acute-care health
services
2. Capability to prospectively plan budgets and resource needs
3. Sufficient size to support comprehensive, valid, and reliable measurement of
performance (Devers and Berenson 2009, 2)
