HIMT201 Reimbursement, Exam 1
Questions and Answers
CM1500 - ANS-Physician who sees a patient in the office.
In the US, what is healthcare insurance? - ANS-Reduction of a person's or a group's
exposure to risk for unknown healthcarecosts by the assumption of that risk by an
entity.
Claim - ANS-the physician's office sent a request for payment to Able Insurance. The
term used in the HC insdutry for this payment is?
Charge - ANS-The dollar amount for each CPT procedure or service. This is a standard
fee for the item and not the actual amount paid by the third-party-payer.
Allowable Charge - ANS-Average or maximum amount the third party payer will
reimburse providers for the service.
Contractual Allowance - ANS-The difference between what is charged and what is paid
is known as?
Versions of the discounted fee for service payment method include UCR and Capitation.
- ANS-False
Worker's Compensation Insurance - ANS-A patient saw a neurosurgeon for treatment of
a nerve that was severed in an industrial accident. The patient worked for Basic
Manufacturing Company where the industrial accident occurred. Basic Manufacturing
carried workers' compensation insurance. The workers' compensation insurance paid
the fees of the neurosurgeon. Which entity is the "third-party"?
Retrospective Payment - ANS-In which type of reimbursement methodology, do HC
insurance companies reimburse providers after the costs have been incurred?
Prospective Payment Method - ANS-Which of the following reimbursement methods
pays providers according to charges that are calculated before healthcare services are
rendered?
Global Payment - ANS-Which of the following apply to radiologist and other procedures
that include professional and technical components and are paid as a lump sum to be
divided between physician and healthcare facility?
, Block Grant - ANS-Fixed amount of money given or allocated for a specific purpose.
Fee-For-Service - ANS-What term is used for retrospective reimbursement charges
submitted by a provider for each service rendered?
Fee-For-Service Reimbursement - ANS-In which type of HC payment method does the
HC plan pay for each service that a provider renders?
Per diem - ANS-In which type of HC payment method does the HC plan recompense
providers with a fixed rate for each day a covered member is hospitalized?
ACO - ANS-All of the following are discounted fee-for service healthcare payment
methods except:
Episode of Care - ANS-The financial manager of the physician group practice explained
that the healthcare insurance company would be reimbursing the practice for its
treatment of the exacerbation of congestive heart failure that Mrs. Zale experienced.
The exacerbation, treatment, and resolution covered approximately five weeks. The
payment covered all the services that Mrs. Zale incurred during the period. What
method of reimbursement was the physician group practice receiving?
Self insured plan - ANS-All of the following are types of Episode of Care reimbursement
except:
Case-based - ANS-From the patient's healthcare plan, the rehab facility received a
fixed, pre-established payment for the patient's rehab after a total knee replacement.
what type of payment method was the patient's insurance using?
Fee Schedule - ANS-What is the term for a predetermined list of charges?
RBRVS (Resource-Based Relative Value Scale) - ANS-From the patient's healthcare
plan, the rehab facility received a fixed, pre-established payment for the patient's rehab
after a total knee replacement. what type of payment method was the patient's
insurance using?
Employment - ANS-To which of the following factors in health insurance status most
closely linked?
Capitated Rate - ANS-The health plan reimburses Dr. Tan $15 per patient per month. In
January, Dr. Tan saw 300 patients, so he received $4,500 from the health plan. What
method is the health plan using to reimburse Dr. Tan?
Capitated rate - ANS-In which type of healthcare payment method, does the healthcare
plan recompense providers each month with a set amount of money for each individual
enrolled in the healthcare plan?
Questions and Answers
CM1500 - ANS-Physician who sees a patient in the office.
In the US, what is healthcare insurance? - ANS-Reduction of a person's or a group's
exposure to risk for unknown healthcarecosts by the assumption of that risk by an
entity.
Claim - ANS-the physician's office sent a request for payment to Able Insurance. The
term used in the HC insdutry for this payment is?
Charge - ANS-The dollar amount for each CPT procedure or service. This is a standard
fee for the item and not the actual amount paid by the third-party-payer.
Allowable Charge - ANS-Average or maximum amount the third party payer will
reimburse providers for the service.
Contractual Allowance - ANS-The difference between what is charged and what is paid
is known as?
Versions of the discounted fee for service payment method include UCR and Capitation.
- ANS-False
Worker's Compensation Insurance - ANS-A patient saw a neurosurgeon for treatment of
a nerve that was severed in an industrial accident. The patient worked for Basic
Manufacturing Company where the industrial accident occurred. Basic Manufacturing
carried workers' compensation insurance. The workers' compensation insurance paid
the fees of the neurosurgeon. Which entity is the "third-party"?
Retrospective Payment - ANS-In which type of reimbursement methodology, do HC
insurance companies reimburse providers after the costs have been incurred?
Prospective Payment Method - ANS-Which of the following reimbursement methods
pays providers according to charges that are calculated before healthcare services are
rendered?
Global Payment - ANS-Which of the following apply to radiologist and other procedures
that include professional and technical components and are paid as a lump sum to be
divided between physician and healthcare facility?
, Block Grant - ANS-Fixed amount of money given or allocated for a specific purpose.
Fee-For-Service - ANS-What term is used for retrospective reimbursement charges
submitted by a provider for each service rendered?
Fee-For-Service Reimbursement - ANS-In which type of HC payment method does the
HC plan pay for each service that a provider renders?
Per diem - ANS-In which type of HC payment method does the HC plan recompense
providers with a fixed rate for each day a covered member is hospitalized?
ACO - ANS-All of the following are discounted fee-for service healthcare payment
methods except:
Episode of Care - ANS-The financial manager of the physician group practice explained
that the healthcare insurance company would be reimbursing the practice for its
treatment of the exacerbation of congestive heart failure that Mrs. Zale experienced.
The exacerbation, treatment, and resolution covered approximately five weeks. The
payment covered all the services that Mrs. Zale incurred during the period. What
method of reimbursement was the physician group practice receiving?
Self insured plan - ANS-All of the following are types of Episode of Care reimbursement
except:
Case-based - ANS-From the patient's healthcare plan, the rehab facility received a
fixed, pre-established payment for the patient's rehab after a total knee replacement.
what type of payment method was the patient's insurance using?
Fee Schedule - ANS-What is the term for a predetermined list of charges?
RBRVS (Resource-Based Relative Value Scale) - ANS-From the patient's healthcare
plan, the rehab facility received a fixed, pre-established payment for the patient's rehab
after a total knee replacement. what type of payment method was the patient's
insurance using?
Employment - ANS-To which of the following factors in health insurance status most
closely linked?
Capitated Rate - ANS-The health plan reimburses Dr. Tan $15 per patient per month. In
January, Dr. Tan saw 300 patients, so he received $4,500 from the health plan. What
method is the health plan using to reimburse Dr. Tan?
Capitated rate - ANS-In which type of healthcare payment method, does the healthcare
plan recompense providers each month with a set amount of money for each individual
enrolled in the healthcare plan?
