Healthcare Reimbursement Systems
Review Questions and Correct Answers
Prospective payment system ✅reimbursement methodology that establishes
predetermined rates based on patient category or type of facility
Prospective cost-based rates ✅healthcare costs from which a prospective per diem
rate is determined - this method may be based on case-mix
Prospective price-based rates ✅associated with a particular category of patient & rates
are established by the payer prior to the provision of health care services
Fee schedule ✅cost-based, fee-for-service reimbursement methodology - includes a
list of maximum fees & corresponding procedures/services which payers use to
compensate providers
Exclusions ✅Medicare PPS Excluded Cancer Hospitals that applied for & were
granted waivers from mandatory participation in the hospital inpatient PPS
Tax Equity and Fiscal Responsibility Act 1983 - TEFRA ✅legislated implementation of
the inpatient prospective payment system, which uses diagnosis-related groups (drgs)
to reimburse short-term hospitals a predetermined rate for Medicare inpatient services
Diagnosis-related groups ✅classify inpatient cases into groups that are expected to
consume similar hospital resources
Major diagnostic categories ✅DRG's that are mutually exclusive categories that are
loosely based on body systems
Outliers ✅inpatient cases that are unusually costly & the IPPS payment is increased to
protect the hospital from large financial losses
UB-04 ✅claim form submitted for inpatient care
Medicare Administrative Contractor (MAC) ✅third-party payer that contracts with
Medicare
IPPS 3-day payment window ✅requires outpatient preadmission services provided by
a hospital up to 3 days prior to a patient's admission to be covered by the IPPS DRG
payment
Review Questions and Correct Answers
Prospective payment system ✅reimbursement methodology that establishes
predetermined rates based on patient category or type of facility
Prospective cost-based rates ✅healthcare costs from which a prospective per diem
rate is determined - this method may be based on case-mix
Prospective price-based rates ✅associated with a particular category of patient & rates
are established by the payer prior to the provision of health care services
Fee schedule ✅cost-based, fee-for-service reimbursement methodology - includes a
list of maximum fees & corresponding procedures/services which payers use to
compensate providers
Exclusions ✅Medicare PPS Excluded Cancer Hospitals that applied for & were
granted waivers from mandatory participation in the hospital inpatient PPS
Tax Equity and Fiscal Responsibility Act 1983 - TEFRA ✅legislated implementation of
the inpatient prospective payment system, which uses diagnosis-related groups (drgs)
to reimburse short-term hospitals a predetermined rate for Medicare inpatient services
Diagnosis-related groups ✅classify inpatient cases into groups that are expected to
consume similar hospital resources
Major diagnostic categories ✅DRG's that are mutually exclusive categories that are
loosely based on body systems
Outliers ✅inpatient cases that are unusually costly & the IPPS payment is increased to
protect the hospital from large financial losses
UB-04 ✅claim form submitted for inpatient care
Medicare Administrative Contractor (MAC) ✅third-party payer that contracts with
Medicare
IPPS 3-day payment window ✅requires outpatient preadmission services provided by
a hospital up to 3 days prior to a patient's admission to be covered by the IPPS DRG
payment
