Reimbursement Final Exam Questions
and Answers
insurance - ANSWER-a system of reducing a person's exposure to risk of loss by
having another party assume the risk
which health insurance model is used in the US? - ANSWER-private health insurance
model
reimbursement - ANSWER-the compensation or repayment for healthcare services
already delivered
prospective payment - ANSWER-type of reimbursement in which the third party payer
establishes the payment rates for healthcare services in advance for a specific time
period
retrospective payment - ANSWER-type of reimbursement in which the payer bases
payment on the actual resources expended to deliver the service
charge - ANSWER-fee
per diem payment - ANSWER-provider is reimbursed a fixed rate for each day a
covered member is hospitalized
fee schedule - ANSWER-predetermined list of maximum allowable fees for each
healthcare service
bundled payment method - ANSWER-predetermined payment amount is provided for all
services required for a single predefined episode-of-care
capitated payment - ANSWER-Provider receives a per member/per month payment for
all services rendered within scope of practice.
premium - ANSWER-amount of money a policyholder must pay periodically in return for
healthcare coverage
OIG Workplan - ANSWER-outlines the areas of focus for compliance for the upcoming
year
What did the Improper Payments information act create? - ANSWER-PERM and CERT
, two forms of benchmarking that can help a manager determine the staff's level of
compliance - ANSWER-internal and external benchmarking
abuse - ANSWER-unknowing or unintentional submission of an inaccurate claim for
payment
Office of Inspector General - ANSWER-investigates issues of noncompliance in the
Medicare and Medicaid programs, such as fraud and abuse
fraud - ANSWER-intentionally making a claim for payment that one knows to be false
What is the least controlled HMO? - ANSWER-PPO
exclusive provider organization - ANSWER-sponsored by self insured employers or
associations
dual eligibles - ANSWER-people who qualify for both medicare and medicaid
steps in assigning MS-DRGs - ANSWER--pre-MDC assignment
-major diagnostic category determination
-medical/surgical determination
-refinement
Which reimbursement scheme is used in the Inpatient Psychiatric Facility Prospective
Payment System? - ANSWER-per diem rate
case mix index - ANSWER-a weighted average of the sum of the RWs of all patients
treated during a specified time
groupers - ANSWER-Computer program using specific data elements to assign
patients, clients, or residents to groups, categories, or classes.
integrated delivery system - ANSWER-single group of organizations that provide care
across a continuum of settings
Sources of evidence based clinical guidelines - ANSWER-US preventive services task
force, AHRQ, CDC, ACA, American Academy of Family Physicians, American Academy
of Ophthalmology, and American College of Obstetricians and gynecologists
patient level adjustments under the IPF PPS - ANSWER-length of stay, medicare
severity DRG adjustment, comorbid condition adjustment, age of patient adjustment,
electronconvulsive therapy
facility level adjustments under the IPF PPS - ANSWER-wage-index, cost of living, rural
location, teaching hospital, emergency facility
and Answers
insurance - ANSWER-a system of reducing a person's exposure to risk of loss by
having another party assume the risk
which health insurance model is used in the US? - ANSWER-private health insurance
model
reimbursement - ANSWER-the compensation or repayment for healthcare services
already delivered
prospective payment - ANSWER-type of reimbursement in which the third party payer
establishes the payment rates for healthcare services in advance for a specific time
period
retrospective payment - ANSWER-type of reimbursement in which the payer bases
payment on the actual resources expended to deliver the service
charge - ANSWER-fee
per diem payment - ANSWER-provider is reimbursed a fixed rate for each day a
covered member is hospitalized
fee schedule - ANSWER-predetermined list of maximum allowable fees for each
healthcare service
bundled payment method - ANSWER-predetermined payment amount is provided for all
services required for a single predefined episode-of-care
capitated payment - ANSWER-Provider receives a per member/per month payment for
all services rendered within scope of practice.
premium - ANSWER-amount of money a policyholder must pay periodically in return for
healthcare coverage
OIG Workplan - ANSWER-outlines the areas of focus for compliance for the upcoming
year
What did the Improper Payments information act create? - ANSWER-PERM and CERT
, two forms of benchmarking that can help a manager determine the staff's level of
compliance - ANSWER-internal and external benchmarking
abuse - ANSWER-unknowing or unintentional submission of an inaccurate claim for
payment
Office of Inspector General - ANSWER-investigates issues of noncompliance in the
Medicare and Medicaid programs, such as fraud and abuse
fraud - ANSWER-intentionally making a claim for payment that one knows to be false
What is the least controlled HMO? - ANSWER-PPO
exclusive provider organization - ANSWER-sponsored by self insured employers or
associations
dual eligibles - ANSWER-people who qualify for both medicare and medicaid
steps in assigning MS-DRGs - ANSWER--pre-MDC assignment
-major diagnostic category determination
-medical/surgical determination
-refinement
Which reimbursement scheme is used in the Inpatient Psychiatric Facility Prospective
Payment System? - ANSWER-per diem rate
case mix index - ANSWER-a weighted average of the sum of the RWs of all patients
treated during a specified time
groupers - ANSWER-Computer program using specific data elements to assign
patients, clients, or residents to groups, categories, or classes.
integrated delivery system - ANSWER-single group of organizations that provide care
across a continuum of settings
Sources of evidence based clinical guidelines - ANSWER-US preventive services task
force, AHRQ, CDC, ACA, American Academy of Family Physicians, American Academy
of Ophthalmology, and American College of Obstetricians and gynecologists
patient level adjustments under the IPF PPS - ANSWER-length of stay, medicare
severity DRG adjustment, comorbid condition adjustment, age of patient adjustment,
electronconvulsive therapy
facility level adjustments under the IPF PPS - ANSWER-wage-index, cost of living, rural
location, teaching hospital, emergency facility
