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Exam (elaborations)
Reimbursement in Healthcare Exam Questions and Correct Answers
Why is Healthcare reimbursement different from other industries? 1. Patients often is not the person who pays 2. Complex contractual relationships between, patient, government, third-party payer, & provider 3. The dollar amount collected by the provider may vary widely depending on who pays 4. The government is the largest single payer and amount paid is not buy price but the reimbursement rules & regulations set by laws Reimbursement types (2) Fee-For-Service Episode-of-care Fee-For-Service T...
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Healthcare Reimbursement Systems Review Questions and Correct Answers
Prospective payment system reimbursement methodology that establishes predetermined rates based on patient category or type of facility Prospective cost-based rates healthcare costs from which a prospective per diem rate is determined - this method may be based on case-mix Prospective price-based rates associated with a particular category of patient & rates are established by the payer prior to the provision of health care services Fee schedule cost-based, fee-for-service reimbursement metho...
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Principles of Healthcare Reimbursement, Chp 1, Part 1 Questions and Correct Answers
The US healthcare system is inherently complex because it is actually multiple subsystems rather than a single system Insurance a system of reducing a person's exposure to risk of loss by having another party (insurance company or insurer) assumes the risk Risk pool group of persons with similar risks of loss Risk In healthcare, is the potential that a person will get sick or require health services and will incur bills (costs) associated with his or her treatment or services. Dependent/fam...
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Chapter 4 Healthcare Reimbursement Methodologies Study Questions and Correct Answers
What is the difference between retrospective and prospective reimbursement? Retrospective reimbursement is based on the actual resources expended to deliver the services and is finalized after the services are delivered. Prospective reimbursement is established prior to the healthcare delivery and does not change based on the costs of the actual services delivered to the patient. There are four guiding principles of prospective payment: 1. Payment rates are to be established in advance and fixe...
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HIM 2330 Healthcare Reimbursement Review Questions and Correct Answers
Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to calculate the group's premiums? To assure that the pool is large enough to pay losses of the entire group Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was cancelled after the patient was diagnosed with mononucleosis. On today's visit the patient is started on prednisone for severe sore throat and difficulty swallowing. The patient wa...
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HIM 151(PRINCIPLES OF HEALTHCARE REIMBURSEMENT) 5TH EDITION QUESTIONS AND CORRECT ANSWERS
What is the name of your state's insurance commission? Bureau of Insurance What is the mission of your state's insurance commission? to ensure that citizens of the Commonwealth are provided with access to adequate and reliable insurance protection; that the insurance companies selling policies are financially sound to support payment of claims; that he agents selling company policies are qualified and conduct their business according to statutory and regulatory requirements, as well as accept...
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Principles of Healthcare Reimbursement & Revenue Cycle Management Questions and Answers
In this healthcare delivery model, the government is the only payer that funds universal healthcare coverage through taxes NATIONAL INSURANCE MODEL In this healthcare delivery model, the insurance company determines that contribution amount that is not based on the policyholder's income PRIVATE INSURANCE MODEL In this healthcare delivery model, employees and employers contribute an income-based amount of money to funds that are regulated by the government SOCIAL INSURANCE MODEL The US health...
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Reimbursement Methodologies Practice Questions and Correct Answers
Episode-of-Care determine payment based on one lump sum payment for all the care provided related to a disease or particular condition. (time factor) - unit of time may be daily, monthly, or other specific time period Managed Care- Capitation Reimbursement method - third-party payer contracts with the healthcare provider to pay a flat fee per individual enrolled in the healthcare plan. The actual services provided to the patient - few or numerous - dont affect the reimbursement to the provider ...
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Healthcare Reimbursement Methodologies Test Questions and Correct Answers
Healthcare reimbursement methodologies breakdown into two primary types: 1- Fee-For-Service, Reimbursement based on: •Services provided to the patient 1.Self-pay 2.Retrospective payment 3.Managed care 2. Episode-of-Care, Patient's condition/illness •A specified time period 1.Managed care - capitation 2.Global payment 3.Prospective payment Third party payer Entity other than the patient reimburses provider for services Fee-for-service reimbursement is payment in which providers receive pa...
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Healthcare Reimbursement Chapter 6 Test Questions and Correct Answers
Balance billing Allowing the provider to charge the patient the difference of the allowed amount from insurance Allowed charge The allowable charge, or payment set by the health care plan for each covered service. This is the maximum fee the health plan will pay for that service or procedure. What are five disadvantages of indemnity plans? Must meet deductible. Patient pays a larger portion of cost. Limited coverage. Preventative care sell them covered. Patient statements must be prepared and ...
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PRINCIPLES OF HEALTHCARE REIMBURSEMENT STUDY GUIDE WITH QUESTIONS AND SOLUTIONS
AHA CODING CLINIC FOR HCPCSAHA CODING CLINIC FOR ICD-10-CM & ICD-10 PCS A publication issued quarterly by the American Hospital Association & approved by the Centers for MC & MK Services (CMS) to give coding advice & direction for International Classification of Diseases, 10th Revision, Clinical Modification & Procedure Coding System( IC10-CM/PCS) WHY HAVE MANY INSURERS REPLACED RETROSPECTIVE REIMBURSEMENT METHODS WITH PROSPECTIVE PAYMENT METHODS? The prospective payment method is an attempt to...
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Healthcare Reimbursement-Chapter 2 Test Questions and Correct Answers
HIPAA (Health Insurance Portability and Accountability Act) Designated the code sets for healthcare services reporting to public and private insurers. HITSP (Health Information Technology Standards Panel) identified standards for the electronic exchange of health information NCHS (National Center for Health Statistics) A division of the CDC responsible for developing and publishing ICD-10 CM in the USA The clinical modification of ICD has several uses: -Classifying morbidity and mortality inf...
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Healthcare Reimbursement Study Guide with Questions and Correct Answers
What are the two types of reimbursement systems Fee-for-service and episode-of-care fee-for-service a system under which doctors and hospitals receive a payment for each service they provide Episode-of care Payment based on services provided for conditions for which the patient is treated. 3 examples of Fee-for-service Self pay, retrospective payment, managed care 3 examples of episode-of-care Managed care capitation, global payment, prospective payment Self pay Patients without third-party...
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Reimbursement Quizzes 1, 3, 4, 5, 7-A, 7-B, 8-A, 8-B, 9, 2, 6, & 10 Final Review Q2uestions and Answers
There are 3 parties in healthcare reimbursement. Who is the second party? Provider of care or services All of the following methods are types of episode-of-care reimbursement EXCEPT: Self-insured plan Which of the three models for health systems predominates in the United States? Private health insurance model Payers that use per-diem payment rates reimburse the provider a fixed rate for each day a covered member is hospitalized. True A patient sees an orthopedic physician for treatment of a...
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Healthcare Reimbursement Mid-Term Exam Questions and Correct Answers
ICD-10-CM The coding system that is used primarily for reporting diagnoses for hospital inpatients CPT coding systems created for reporting procedures and services performed by physicians in clinical practice? WHO ICD is maintained by lessons learned from RAC demonstration -RACs are able to find large volume of improper payments -Overpayments collected were significantly greater than the programs costs -Providers do not appeal every overpayment determination - RACs willing to spend time on pr...
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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...
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Healthcare Reimbursement Review Questions and Correct Answers
Health Care Financing Administration Created in 1977 to coordinate and administer Medicare and Medicaid HIPPA provisions 1. Ensures coverage for preexisting conditions 2. Protects against discrimination based on health status 3. Right to purchase individual plan Healthy People 2000 objectives 1. Health promotion 2. Health protection 3. Preventative services Healthy People 2010 objectives 1. Increasing length/quality of life 2. Eliminating health disparities among different population sectors ...
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Healthcare Reimbursement Chapter 5 Review Questions and Correct Answers
Arithmetic Mean Length of Stay (AMLOS) Sum of all lengths of stay in a set of cases divided by the number of cases. Base Payment Rate 1) Rate per discharge for operating and capital-related components for an acute-care hospital. 2) Prospectively set payment rate made for services that Medicare beneficiaries receive in healthcare settings. The base rate is adjusted for geographic location, inflation, case mix, and other factors. Case Mix Set of categories of patients (type and volume) treated b...
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Healthcare Reimbursement Ch. 8 Test Questions and Correct Answers
Activities of daily living (ADL) Everyday tasks that people can perform without assistance and that are used to measure their functional status and, thus, their need for institutional or assisted care. Average length of stay (ALOS) Average number of days patients are hospitalized. Base rate 1. Rate per discharge for operating and capital-related components for an acute-care hospital. 2. Prospectively set payment rate made for services that Medicare beneficiaries receive in healthcare settings....
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Healthcare Reimbursement Final Exam Questions and Answers Already Passed
Healthcare Reimbursement Final Exam Questions and Answers Already Passed What is the difference between direct and indirect costs in healthcare? Direct costs are expenses directly tied to patient care, such as salaries and medical supplies, while indirect costs are overhead expenses, like administrative salaries and utilities. What role do diagnosis-related groups (DRGs) play in reimbursement? DRGs categorize hospital cases into groups that determine the fixed payment amount for i...
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