Chapter 7 Medicare Prospective
Payment Systems Questions & Answers
Bad Debt - ANSWERSWhen a health care facility provides services to a patient fully
expecting to be paid but the payer does not pay, the amount for the service is charged
off to this account.
Comorbidity - ANSWERSA specific patient condition that is secondary to a patient's
principal diagnosis.
Diagnosis-Related Groups - ANSWERSGroups that are assigned to each patient based
on their diagnosis at the time of discharge.
Disproportionate Share Hospital (DSH) - ANSWERSA hospital that treats a high
percentage of low-income patients and receives a percentage add-on payment that will
be applied to the DRG-adjusted based payment rate.
Fiscal Intermediary - ANSWERSMedicare payment branch that is local and which is
contracted with the public or private providers and act as agents of the federal
government.
Geometric Mean Length of Stay (GMLOS) - ANSWERSA measurement that takes an
adjustment for the outliers, transfer cases and negative outlier cases and gives a
statistically adjusted value for the length of stay. In addition, it is used to calculate
transfer case payments.
Health Insurance Prospective Payment System (PPS) - ANSWERSRate codes that
represent specific sets of patient characteristics or case-mix groups on which payment
determinations are made under several prospective payment systems. These payment
systems use clinical data s the basic input to determine which case-mix group applies to
a particular patient. These codes are used for Inpatient Rehabilitation Facilities (IRF),
Home Health Agencies (HH) and Skilled Nursing Facilities (SNF).
Hospital Wage Index - ANSWERSAn adjustment based on the geographical location of
a hospital and their area wage level as compared to the national average. This is
adjusted annually.
Indirect Medical Education - ANSWERSSection 1886 (d)(5)(B) of the Social Security Act
provides that PPS hospitals that have medical residents in an approved Graduate
Medical Education (GME) program will receive an additional payment for a Medicare
discharge. This higher payment will reflect the additional costs that are incurred by
teaching hospitals as opposed to a non-teaching facility.
Payment Systems Questions & Answers
Bad Debt - ANSWERSWhen a health care facility provides services to a patient fully
expecting to be paid but the payer does not pay, the amount for the service is charged
off to this account.
Comorbidity - ANSWERSA specific patient condition that is secondary to a patient's
principal diagnosis.
Diagnosis-Related Groups - ANSWERSGroups that are assigned to each patient based
on their diagnosis at the time of discharge.
Disproportionate Share Hospital (DSH) - ANSWERSA hospital that treats a high
percentage of low-income patients and receives a percentage add-on payment that will
be applied to the DRG-adjusted based payment rate.
Fiscal Intermediary - ANSWERSMedicare payment branch that is local and which is
contracted with the public or private providers and act as agents of the federal
government.
Geometric Mean Length of Stay (GMLOS) - ANSWERSA measurement that takes an
adjustment for the outliers, transfer cases and negative outlier cases and gives a
statistically adjusted value for the length of stay. In addition, it is used to calculate
transfer case payments.
Health Insurance Prospective Payment System (PPS) - ANSWERSRate codes that
represent specific sets of patient characteristics or case-mix groups on which payment
determinations are made under several prospective payment systems. These payment
systems use clinical data s the basic input to determine which case-mix group applies to
a particular patient. These codes are used for Inpatient Rehabilitation Facilities (IRF),
Home Health Agencies (HH) and Skilled Nursing Facilities (SNF).
Hospital Wage Index - ANSWERSAn adjustment based on the geographical location of
a hospital and their area wage level as compared to the national average. This is
adjusted annually.
Indirect Medical Education - ANSWERSSection 1886 (d)(5)(B) of the Social Security Act
provides that PPS hospitals that have medical residents in an approved Graduate
Medical Education (GME) program will receive an additional payment for a Medicare
discharge. This higher payment will reflect the additional costs that are incurred by
teaching hospitals as opposed to a non-teaching facility.
