HFMA CRCR 2024 chapter 2 Correctly Answered

HFMA CRCR 2024 chapter 2 Correctly Answered HMO A health plan that provides comprehensive healthcare services, within a designated population, on a pre-payment basis.(2.5 Health Plans) PPO A health plan that provides comprehensive healthcare services, within a designated population, on a pre-payment basis.(2.5 Health Plans) CDHP Subscriber agrees to a high initial deductible, in return for lower premiums.(2.5 Health Plans) POS Members can refer themselves outside the plan and still get some coverage (2.5 Health Plans) Review Your Knowledge Which option is NOT a specific managed care requirement? A. Referrals B. Notification C. Preferred Provider Organization D. Discharge Planning (2.5 chapter review) C. Preferred Provider Organization Preferred Provider Organization (PPO) is a form of managed care which is the closest to an indemnity plan. PPO is not a specific managed care requirement. It is a health plan where the employer and the health plan contract to purchase healthcare services for covered beneficiaries from a selected group of participating providers. Review Your Knowledge 2.1 Pt types Which patients are considered scheduled? A. Observation Patients B. Emergency Department PatientsC. Recurring/Series Patients D. Hospice Care C. Recurring/Series Patients Patients who receive services where the treatment is ongoing are registered as recurring or series patients and are categorized as scheduled. Services for scheduled patients are high-dollar and require significant pre processing to ensure appropriate reimbursement and/or significant resource coordination. Good job! Review Your Knowledge 2.2 Name the guideline that Medicare established to determine which diagnoses, signs, or symptoms are payable. A. Patient Identifiers B. Local Coverage Determinations C. Advance Beneficiary Notice D. Scheduling Instructions B. Local Coverage Determinations Medicare and other health plans will only pay for tests and services that are determined to be "reasonable and necessary". Medicare has established guidelines called Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) that are used to determine which diagnoses, signs, or symptoms are payable. If a test is ordered where an LCD or NCD exists, there must be documentation of medical necessity in order for Medicare to pay for the test or service. Good job! Review Your Knowledge 2.3 pre-reg and insurance verification What is the purpose of insurance verification?