HIMS 5620 Exam 2 Questions with Correct Answers Latest Update 2026/2027

HIMS 5620 Exam 2 Questions with Correct Answers Latest Update 2026/2027 Fee Schedule - Answers Retrospective reimbursement where there is a predetermined list of fees that the payer allows for payment for a set of healthcare services Percent of Billed Charges - Answers Retrospective reimbursement where the payer has negotiated to pay a reduced fee for services provided to their insureds Per Diem - Answers Retrospective reimbursement where the payer reimburses the provider a fixed rate for each day a covered member is hospitalized Capitation - Answers Prospective reimbursement where the payer reimburses the provider a fixed, per capita amount for a defined period (Per member per month) Case Rate - Answers Prospective reimbursement where the payer reimburses the provider one amount for the entire admission or encounter regardless of the number of services or length of admission Global Payment - Answers Prospective reimbursement where there is one combined payment to cover the services of multiple providers who are treating a single episode of care (typically physician services/outpatient care) Bundled Payment - Answers Prospective reimbursement where there is a predetermined payment amount provided for all services required for a single predefined episode of care. CMS-HCC Model - Answers Risk adjustment model that uses patient demographic characteristics and medical conditions to predict the patient's healthcare costs Risk Adjustment - Answers Statistical process that considers the underlying health status and health spending of patients when examining their healthcare outcomes or healthcare costs. Risk Score - Answers Risk score of 1 represents the average Medicare beneficiary Risk score > 1 means the beneficiary will cost more than the average Medicare beneficiary Risk score < 1 means the beneficiary will cost less than the average Medicare beneficiary Raw Risk Score - Answers Demographic + Coding Risk Scores Federal Register Rule Progression - Answers Notice of Proposed Rule Making -> Comment Period -> Final Rule Cost Report - Answers Form that collects information about institutional providers to make proper determinations of amounts payable under its provisions in various PPPs Value-Based Purchasing (VBP) - Answers Payment model that links quality to reimbursement Pay for Reporting - Answers Medicare's first attempt at linking quality to reimbursement MS-DRGs - Answers Organizes inpatient admissions into large groups for reimbursement purposes by taking into consideration the role that a hospital's composition of patients plays into influencing costs Resource Intensity - Answers Measures the amount of resources required to treat a patient Relative Weight - Answers Represents the resource intensity of a classification group Case-Mix Index - Answers A weighted average of the sum of the relative weights of all patients treated during a specified time Case-Mix Index (MS-DRG perspective) - Answers Direct measure of the resource consumption and the cost of providing care (high case-mix= patients consuming lots of resources and higher cost of care) MS-DRG Structure - Answers MDC (body system) -> Surgical/Medical -> Individual MS-DRGS Severity of Illness - Answers Extent of physiological decompensation or organ system loss of function Complication vs Comorbidity - Answers Complication: Medical condition that arises during the hospital stay that prolongs LOS at least 1 day Comorbidity: Pre-existing condition that causes an increase in LOS by at least 1 day MCC vs CC vs Non-CC/MCC - Answers MCC: Secondary condition that have a major severity of illness and impact on resource use