MEDICAL BILLING AND HEALTH
INSURANCE QUESTIONS AND
ANSWERS WITH SOLUTIONS 2024
Claim - ANSWER A bill for services submitted by a healthcare provider
healthcare providers - ANSWER People or facilities that provide health care services (hospitals, doctor
offices)
Third-party payer - ANSWER Those who reimburse healthcare providers for delivering services.
reimbursement - ANSWER Compensation or repayment for healthcare services how much doctors are
paid
universal health care - ANSWER Healthcare provided to all people regardless of age, sex, religion, income
level.
Preventable Health Threats - ANSWER illnesses that can be prevented before they occur by routine
physical examinations and immunizations
Chargemaster - ANSWER document that contains a computer-generated list of procedures, services, and
supplies with charges for each; chargemaster data are entered in the facility's patient accounting system,
and charges are automatically posted to the patient's bill (UB-04).
fee schedule - ANSWER a document that specifies the amount the provider bills for provided services
Episode-of-care reimbursement - ANSWER issue a lump-sum payment to providers to compensate them
for all healthcare services delivered to a patient for a specific illness over a specific period of time. AKA
bundled payments
ambulatory surgery center - ANSWER State licensed, Medicare-certified supplier of surgical healthcare
services.
, Ambulatory Payment Classification (APC) - ANSWER Prospective payment system used to calculate
reimbursement for outpatient care according to similar clinical characteristics and in terms of resources
required.
Fee-for-service reimbursement - ANSWER Healthcare provider receives reimbursement based on the
amount that they charge for service.
Covered Medical Expenses - ANSWER Expenses that are listed in the benefit section of the insurance
policy.
admitting diagnosis - ANSWER A provisional description of the reason why a patient requires care in an
inpatient hospital setting
Case Mix - ANSWER A method of grouping patients according to a predefined set of characteristics.
Comborbidities - ANSWER Additional illnesses present at the time of patient admission of the hospital,
often complicating patients treatment or prolonging patient stay.
principal diagnosis - ANSWER a diagnosis that is found after testing and study to be the main reason for
the patients need for healthcare services
Resource-Based Relative Value Scale (RBRVS) - ANSWER Reimbursement system according to a fee
schedule based on predetermined values.
Medicare fee schedule (MFS) - ANSWER The RBRVS-based allowed fees that are reimbursable to
Medicare participating physicians.
Skilled Nursing Facility (SNF) - ANSWER Prospective payment system- PPS that overs all cost associated
with SNF services for Medicare Part A beneficiaries.
Healthcare Common Procedure Coding System (HCPCS) - ANSWER Codinf system for patient services
that are reported on Medicare Part B bills.
INSURANCE QUESTIONS AND
ANSWERS WITH SOLUTIONS 2024
Claim - ANSWER A bill for services submitted by a healthcare provider
healthcare providers - ANSWER People or facilities that provide health care services (hospitals, doctor
offices)
Third-party payer - ANSWER Those who reimburse healthcare providers for delivering services.
reimbursement - ANSWER Compensation or repayment for healthcare services how much doctors are
paid
universal health care - ANSWER Healthcare provided to all people regardless of age, sex, religion, income
level.
Preventable Health Threats - ANSWER illnesses that can be prevented before they occur by routine
physical examinations and immunizations
Chargemaster - ANSWER document that contains a computer-generated list of procedures, services, and
supplies with charges for each; chargemaster data are entered in the facility's patient accounting system,
and charges are automatically posted to the patient's bill (UB-04).
fee schedule - ANSWER a document that specifies the amount the provider bills for provided services
Episode-of-care reimbursement - ANSWER issue a lump-sum payment to providers to compensate them
for all healthcare services delivered to a patient for a specific illness over a specific period of time. AKA
bundled payments
ambulatory surgery center - ANSWER State licensed, Medicare-certified supplier of surgical healthcare
services.
, Ambulatory Payment Classification (APC) - ANSWER Prospective payment system used to calculate
reimbursement for outpatient care according to similar clinical characteristics and in terms of resources
required.
Fee-for-service reimbursement - ANSWER Healthcare provider receives reimbursement based on the
amount that they charge for service.
Covered Medical Expenses - ANSWER Expenses that are listed in the benefit section of the insurance
policy.
admitting diagnosis - ANSWER A provisional description of the reason why a patient requires care in an
inpatient hospital setting
Case Mix - ANSWER A method of grouping patients according to a predefined set of characteristics.
Comborbidities - ANSWER Additional illnesses present at the time of patient admission of the hospital,
often complicating patients treatment or prolonging patient stay.
principal diagnosis - ANSWER a diagnosis that is found after testing and study to be the main reason for
the patients need for healthcare services
Resource-Based Relative Value Scale (RBRVS) - ANSWER Reimbursement system according to a fee
schedule based on predetermined values.
Medicare fee schedule (MFS) - ANSWER The RBRVS-based allowed fees that are reimbursable to
Medicare participating physicians.
Skilled Nursing Facility (SNF) - ANSWER Prospective payment system- PPS that overs all cost associated
with SNF services for Medicare Part A beneficiaries.
Healthcare Common Procedure Coding System (HCPCS) - ANSWER Codinf system for patient services
that are reported on Medicare Part B bills.
