HEALTHCARE REIMBURSEMENT-
Study Guide ACTUAL QUESTIONS AND
CORRECT ANSWERS
Accountable care organization - CORRECT ANSWERS Population
based model for healthcare
allowable charge - CORRECT ANSWERS Amount the payer will
reimburse providers for the service
Attribution - CORRECT ANSWERS Assignment of a beneficiary to
particular organization
Billed charges - CORRECT ANSWERS Amount the provider is actually
charging for a service
Giant ACO has agreed to a shared savings rate of 65 percent and a shared loss
rate of 40 percent with CMS. Giant ACO participates in a __________ risk
agreement. - CORRECT ANSWERS Two-sided
In the CMS ACO model, what is attribution? - CORRECT ANSWERS A
beneficiary is assigned to a particular ACO.
In the CMS-HCC model, beneficiaries with a risk score greater than 1 have
___________? - CORRECT ANSWERS A higher expected cost of care
than the average Medicare beneficiary
The CMS-HCC model uses ___________ and __________ to predict the
patient's healthcare costs. - CORRECT ANSWERS Patient demographic
characteristics; health status
,The pathologist's office submitted a $54 bill for a laboratory test. In its payment
notice (remittance advice), the healthcare plan lists its payment for the
laboratory test as $28. What does the amount of $54 represent? - CORRECT
ANSWERS Billed charges
Patient 62316 is admitted as an inpatient for hip replacement following a fall on
ice in the school parking lot where he works as a teacher. During his admission,
the patient received OT services post-surgery. The LOS was six days. The
charges for the encounter are $135,000. Which payer will reimburse the hospital
the highest amount? - CORRECT ANSWERS There is not enough
information in the contract matrix to determine reimbursement for this
encounter.
Patient 24571 is seen in the Occupational Therapy (OT) clinic for an initial
evaluation of her carpal tunnel surgery recovery. The charges for the visit total
$150. Which payer will reimburse the facility the highest amount? - CORRECT
ANSWERS Payer B
Patient 89423 is seen in the outpatient clinic at Happy Hospital for a pneumonia
follow-up visit. The charges for the encounter total $135. Which payer will
reimburse the hospital the lowest amount? - CORRECT ANSWERS
Payer D
Patient 72341 is admitted as an inpatient for delivery. Length of stay is three
days. The charges for the encounter are $10,425.00. The cost of the encounter is
$5,848.45. Which payer will reimburse the hospital the highest amount? -
CORRECT ANSWERS Payer B
CMS uses which reimbursement methodology for inpatient psychiatric facility
services payment system because a specific payment rate is established for each
day of the admission? - CORRECT ANSWERS Per diem
,CMS uses this reimbursement methodology when they contract with Medicare
Advantage Payers to care for Medicare beneficiaries under Medicare Part C. -
CORRECT ANSWERS Capitation
Dayna is analyst at Community Hospital. She is examining inpatient cases for
the payer Super Payer. She notices that all pneumonia cases have the
reimbursement amount of $4,000 and that all CHF cases have a reimbursement
rate of $4,200. The reimbursement is consistent for the entire year. Which
reimbursement methodology is Super Payer using to reimbursement
Community Hospital for inpatient admissions? - CORRECT ANSWERS
Case-rate methodology
Dr. McGee is a primary care physician. Several of Dr. McGee's patients are
insured by Super Payer. Super Payer reimburses Dr. McGee for each service she
provides during a clinic visit. Which reimbursement methodology does Super
Payer use to reimburse Dr. McGee? - CORRECT ANSWERS Fee
schedule
Dr. Ward is an endocrinologist who is part of the City Endocrinologist
Specialists practice. Super Payer reimburses City Endocrinologist Specialists
$450 per month for each of the 250 beneficiaries assigned to their care. Which
type of reimbursement methodology is Super Payer using to reimburse City
Endocrinologist Specialists? - CORRECT ANSWERS Capitation
Dr. Jones is a podiatrist who performs over 100 bunionectomies a year. Several
of Dr. Jones' patients are insured by Super Payer. Super Payer reimburses Dr.
Jones one amount for the preoperative visit, the surgery, and routine post-
operative follow-up visits. Which reimbursement methodology does Super
Payer use to reimburse Dr. Jones? - CORRECT ANSWERS Global
payment method
Which of the following statements about retrospective reimbursement is false? -
CORRECT ANSWERS The fewer services performed the greater the
potential for increased total reimbursement
, Bundled payment - CORRECT ANSWERS In this methodology, a
predetermined payment amount is paid to the provider for all services required
for a predefined condition and time frame.
Case Rate - CORRECT ANSWERS Payer reimburses the provider one
amount for the entire admission or encounter regardless of the number of
services or length of admission.
Percent of billed charges - CORRECT ANSWERS In this methodology,
the payer has negotiated to pay a reduced amount instead of the full charge for a
healthcare service.
Global payment - CORRECT ANSWERS In this methodology, the
payer reimburses the provider(s) a single amount to cover all applicable services
provided for an established time frame.
Capitation - CORRECT ANSWERS System of payment used by
managed care plans in which physicians and hospitals are paid a fixed, per
capita amount for each patient enrolled over a stated period regardless of the
type and number of services provided; reimbursement to the hospital on a per-
member/per-month basis to cover costs for the members of the plan.
Which reimbursement methodology is used in IPPS? - CORRECT ANSWERS
Case rate methodology
Which severity of illness level is reflected by MCC codes? - CORRECT
ANSWERS Major
Fatima is calculating the MS-DRG for an inpatient admission. She has
determined that the encounter does not quality for pre-MDC assignment. What
Study Guide ACTUAL QUESTIONS AND
CORRECT ANSWERS
Accountable care organization - CORRECT ANSWERS Population
based model for healthcare
allowable charge - CORRECT ANSWERS Amount the payer will
reimburse providers for the service
Attribution - CORRECT ANSWERS Assignment of a beneficiary to
particular organization
Billed charges - CORRECT ANSWERS Amount the provider is actually
charging for a service
Giant ACO has agreed to a shared savings rate of 65 percent and a shared loss
rate of 40 percent with CMS. Giant ACO participates in a __________ risk
agreement. - CORRECT ANSWERS Two-sided
In the CMS ACO model, what is attribution? - CORRECT ANSWERS A
beneficiary is assigned to a particular ACO.
In the CMS-HCC model, beneficiaries with a risk score greater than 1 have
___________? - CORRECT ANSWERS A higher expected cost of care
than the average Medicare beneficiary
The CMS-HCC model uses ___________ and __________ to predict the
patient's healthcare costs. - CORRECT ANSWERS Patient demographic
characteristics; health status
,The pathologist's office submitted a $54 bill for a laboratory test. In its payment
notice (remittance advice), the healthcare plan lists its payment for the
laboratory test as $28. What does the amount of $54 represent? - CORRECT
ANSWERS Billed charges
Patient 62316 is admitted as an inpatient for hip replacement following a fall on
ice in the school parking lot where he works as a teacher. During his admission,
the patient received OT services post-surgery. The LOS was six days. The
charges for the encounter are $135,000. Which payer will reimburse the hospital
the highest amount? - CORRECT ANSWERS There is not enough
information in the contract matrix to determine reimbursement for this
encounter.
Patient 24571 is seen in the Occupational Therapy (OT) clinic for an initial
evaluation of her carpal tunnel surgery recovery. The charges for the visit total
$150. Which payer will reimburse the facility the highest amount? - CORRECT
ANSWERS Payer B
Patient 89423 is seen in the outpatient clinic at Happy Hospital for a pneumonia
follow-up visit. The charges for the encounter total $135. Which payer will
reimburse the hospital the lowest amount? - CORRECT ANSWERS
Payer D
Patient 72341 is admitted as an inpatient for delivery. Length of stay is three
days. The charges for the encounter are $10,425.00. The cost of the encounter is
$5,848.45. Which payer will reimburse the hospital the highest amount? -
CORRECT ANSWERS Payer B
CMS uses which reimbursement methodology for inpatient psychiatric facility
services payment system because a specific payment rate is established for each
day of the admission? - CORRECT ANSWERS Per diem
,CMS uses this reimbursement methodology when they contract with Medicare
Advantage Payers to care for Medicare beneficiaries under Medicare Part C. -
CORRECT ANSWERS Capitation
Dayna is analyst at Community Hospital. She is examining inpatient cases for
the payer Super Payer. She notices that all pneumonia cases have the
reimbursement amount of $4,000 and that all CHF cases have a reimbursement
rate of $4,200. The reimbursement is consistent for the entire year. Which
reimbursement methodology is Super Payer using to reimbursement
Community Hospital for inpatient admissions? - CORRECT ANSWERS
Case-rate methodology
Dr. McGee is a primary care physician. Several of Dr. McGee's patients are
insured by Super Payer. Super Payer reimburses Dr. McGee for each service she
provides during a clinic visit. Which reimbursement methodology does Super
Payer use to reimburse Dr. McGee? - CORRECT ANSWERS Fee
schedule
Dr. Ward is an endocrinologist who is part of the City Endocrinologist
Specialists practice. Super Payer reimburses City Endocrinologist Specialists
$450 per month for each of the 250 beneficiaries assigned to their care. Which
type of reimbursement methodology is Super Payer using to reimburse City
Endocrinologist Specialists? - CORRECT ANSWERS Capitation
Dr. Jones is a podiatrist who performs over 100 bunionectomies a year. Several
of Dr. Jones' patients are insured by Super Payer. Super Payer reimburses Dr.
Jones one amount for the preoperative visit, the surgery, and routine post-
operative follow-up visits. Which reimbursement methodology does Super
Payer use to reimburse Dr. Jones? - CORRECT ANSWERS Global
payment method
Which of the following statements about retrospective reimbursement is false? -
CORRECT ANSWERS The fewer services performed the greater the
potential for increased total reimbursement
, Bundled payment - CORRECT ANSWERS In this methodology, a
predetermined payment amount is paid to the provider for all services required
for a predefined condition and time frame.
Case Rate - CORRECT ANSWERS Payer reimburses the provider one
amount for the entire admission or encounter regardless of the number of
services or length of admission.
Percent of billed charges - CORRECT ANSWERS In this methodology,
the payer has negotiated to pay a reduced amount instead of the full charge for a
healthcare service.
Global payment - CORRECT ANSWERS In this methodology, the
payer reimburses the provider(s) a single amount to cover all applicable services
provided for an established time frame.
Capitation - CORRECT ANSWERS System of payment used by
managed care plans in which physicians and hospitals are paid a fixed, per
capita amount for each patient enrolled over a stated period regardless of the
type and number of services provided; reimbursement to the hospital on a per-
member/per-month basis to cover costs for the members of the plan.
Which reimbursement methodology is used in IPPS? - CORRECT ANSWERS
Case rate methodology
Which severity of illness level is reflected by MCC codes? - CORRECT
ANSWERS Major
Fatima is calculating the MS-DRG for an inpatient admission. She has
determined that the encounter does not quality for pre-MDC assignment. What
