Principles of Reimbursement Study
Questions and Correct Answers
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? ✅Capitated rate
In which type of healthcare payment method does the healthcare plan pay for each
service that a provider renders ✅Fee-for-service reimbursement
Which healthcare payment method does Medicare use to reimburse physicians based
on the cost of providing services in terms of effort, overhead, and malpractice
insurance? ✅Resource-based relative value scale
Which of the four models for health systems predominates in the United States?
✅Private health insurance model
From the patient's healthcare insurance plan, the rehabilitation facility received a fixed,
pre-established payment for the patient rehabilitation after a total knee replacement.
What type of healthcare payment method was the patient's healthcare insurance plan
using? ✅Case-based
In the United States, what is healthcare insurance? ✅Reduction of a person's or a
group's exposure to risk for unknown healthcare costs by the assumption of that risk by
an entity
In the US health system, which payer has the greatest influence on payment methods
✅Federal government
In which type of reimbursement methodology do healthcare insurance companies
reimburse providers after the costs have been incurred? ✅Retrospective payment
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? ✅Episode-of-care
In its payment notice (remittance advice), the healthcare plan lists that the payment for
the individual laboratory test is $39.00. The bill that the pathologist's office submitted for
the laboratory test was $45.00. What does the amount of $39.00 represent?
✅Allowable fee
, In which type of healthcare payment method, does the healthcare plan oversee both the
costs of healthcare and the outcomes of care? ✅Managed care
The physician's office sent a request for payment to Able Insurance Company. The term
used in the healthcare industry for this request for payment is a(n): ✅Claim
What is not discounted fee-for-service healthcare payment methods ✅ACO
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"? ✅Workers' compensation insurance
To which of the following factors is health insurance status most closely linked?
✅Employment
Which of the following is not a reason to perform case-mix analysis? ✅Determine the
correct MS-DRG assignment for an encounter
The coding system that is used primarily for reporting diagnoses for hospital inpatients
is known as ✅ICD-9-CM
Which of the following coding systems was created for reporting procedures and
services performed by physicians in clinical practice? ✅CPT
The practice of undercoding can affect a hospital's MS-DRG case-mix in which of the
following ways ✅Makes it lower than warranted by the actual service/resource intensity
of the facility
Which governmental fraud and abuse effort focused on recouping lost funds for the
Medicare Program due to inaccurate coding and billing? $188 million were recovered
during the first two years of this effort. ✅Operation Restore Trust
Under MS-DRGs, all of the following factors influence a facility's case-mix index, except
✅The productivity standard for coders
Recovery Audit Contractors are different from other improper payment review
contractors because ✅RACs audit inpatient and outpatient claims
RACs are charged with finding overpayment and underpayments
RACs are reimbursed on a contingency-based system
Questions and Correct Answers
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? ✅Capitated rate
In which type of healthcare payment method does the healthcare plan pay for each
service that a provider renders ✅Fee-for-service reimbursement
Which healthcare payment method does Medicare use to reimburse physicians based
on the cost of providing services in terms of effort, overhead, and malpractice
insurance? ✅Resource-based relative value scale
Which of the four models for health systems predominates in the United States?
✅Private health insurance model
From the patient's healthcare insurance plan, the rehabilitation facility received a fixed,
pre-established payment for the patient rehabilitation after a total knee replacement.
What type of healthcare payment method was the patient's healthcare insurance plan
using? ✅Case-based
In the United States, what is healthcare insurance? ✅Reduction of a person's or a
group's exposure to risk for unknown healthcare costs by the assumption of that risk by
an entity
In the US health system, which payer has the greatest influence on payment methods
✅Federal government
In which type of reimbursement methodology do healthcare insurance companies
reimburse providers after the costs have been incurred? ✅Retrospective payment
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? ✅Episode-of-care
In its payment notice (remittance advice), the healthcare plan lists that the payment for
the individual laboratory test is $39.00. The bill that the pathologist's office submitted for
the laboratory test was $45.00. What does the amount of $39.00 represent?
✅Allowable fee
, In which type of healthcare payment method, does the healthcare plan oversee both the
costs of healthcare and the outcomes of care? ✅Managed care
The physician's office sent a request for payment to Able Insurance Company. The term
used in the healthcare industry for this request for payment is a(n): ✅Claim
What is not discounted fee-for-service healthcare payment methods ✅ACO
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"? ✅Workers' compensation insurance
To which of the following factors is health insurance status most closely linked?
✅Employment
Which of the following is not a reason to perform case-mix analysis? ✅Determine the
correct MS-DRG assignment for an encounter
The coding system that is used primarily for reporting diagnoses for hospital inpatients
is known as ✅ICD-9-CM
Which of the following coding systems was created for reporting procedures and
services performed by physicians in clinical practice? ✅CPT
The practice of undercoding can affect a hospital's MS-DRG case-mix in which of the
following ways ✅Makes it lower than warranted by the actual service/resource intensity
of the facility
Which governmental fraud and abuse effort focused on recouping lost funds for the
Medicare Program due to inaccurate coding and billing? $188 million were recovered
during the first two years of this effort. ✅Operation Restore Trust
Under MS-DRGs, all of the following factors influence a facility's case-mix index, except
✅The productivity standard for coders
Recovery Audit Contractors are different from other improper payment review
contractors because ✅RACs audit inpatient and outpatient claims
RACs are charged with finding overpayment and underpayments
RACs are reimbursed on a contingency-based system
