Reimbursement Final Exam with
Complete Solutions
HOPPS or OPPS
Hospital Outpatient Prospective Payment System - ANSWER-Under the Medicare out
patient prospective payment system, outpatient services include
Recovery Room
Supplies
Anesthesia
*The classification is a resource-based reimbursement system. The payment unit is the
ambulatory payment classification group (APC group).
End Stage Renal Disease Quality Incentive Program (ESRD PPS) - ANSWER-Case
rate reimbursement methodology
o Sometimes referred to as composite rate (leftover language from previous payment
system)
o Several adjustments to account for patient and facility differences
o Ensures reimbursement reflects costs
o Adjustments are called patient multipliers (PM) in this system
Hospice PPS - ANSWER-•No deductible
•Prescriptions - 5% coinsurance (not to exceed $5) for each outpatient prescription
•Inpatient respite care - 5% of Medicare's respite care payment per day, not to exceed
Part A inpatient deductible ($1,340 FY 2018)
•Daily rate is not related to amount of services
•Payment for a day with no services is equal to a day with many services
•Daily rate does not include costs of services unrelated to terminal illness (Medicare
Part A and B, as applicable)
ambulatory surgical center (ASC) - ANSWER-designated surgical services to Medicare
beneficiaries, under part b, must be medicare certified.
-Medicare makes a single payment to ASCs for covered surgical procedure, including
ASC facility services furnished in connection with the covered procedure
List three items not included in ASC payments for covered surgical procedure or
covered ancillary services: - ANSWER-Physicians' Services
Ambulance Services
Non-Implantable Prosthetic Devices
, Under the ASC PPS Medicare payment equal ____ percent and the beneficiary
copayment equals ___ of the total reimbursement for services provided - ANSWER-
80/20
Under the ASC List multiple procedures performed during the same surgical session are
reimbursed at which of the following rate? - ANSWER-The procedure in the highest
APC receives full payment and the remaining procedures receive half (50%) payment.
ambulatory surgical center (ASC) PPS - ANSWER-uses HCPCS coding system,
payment based on APC group relative weight.
ASCs are used for the following cases. - ANSWER-Outpatient (typically) cases up to
Acuity Level III
•Non-emergent cases
•Almost every specialty except cardio and
neurology
Medicare-certified ASCs must accept assignment, meaning? - ANSWER-An ASC must
accept Medicare payment as payment in full
ASC PPS codes? - ANSWER-HCPCS Level I and II
Federally Qualified Health Centers (FQHC PPS) - ANSWER-Medicare reimbursement
system implemented in 2014 to compensate federally qualified health centers according
to a prospectively established base rate for geographic locality and patients'
characteristics.
What are the two types of reimbursement systems - ANSWER-Fee-for-service and
episode-of-care
fee for service system - ANSWER-a system under which doctors and hospitals receive
a payment for each service they provide
episode of care system - ANSWER-covers all the care a patient receives in the course
of treatment for a specific illness, condition or medical event
3 examples of Fee-for-service - ANSWER-Self pay, retrospective payment, managed
care
3 examples of episode-of-care - ANSWER-Managed care capitation, global payment,
prospective payment
Characteristics of HMOs - ANSWER-Entity that combines the provision of healthcare
insurance and the delivery of healthcare services.
Characterized by
Complete Solutions
HOPPS or OPPS
Hospital Outpatient Prospective Payment System - ANSWER-Under the Medicare out
patient prospective payment system, outpatient services include
Recovery Room
Supplies
Anesthesia
*The classification is a resource-based reimbursement system. The payment unit is the
ambulatory payment classification group (APC group).
End Stage Renal Disease Quality Incentive Program (ESRD PPS) - ANSWER-Case
rate reimbursement methodology
o Sometimes referred to as composite rate (leftover language from previous payment
system)
o Several adjustments to account for patient and facility differences
o Ensures reimbursement reflects costs
o Adjustments are called patient multipliers (PM) in this system
Hospice PPS - ANSWER-•No deductible
•Prescriptions - 5% coinsurance (not to exceed $5) for each outpatient prescription
•Inpatient respite care - 5% of Medicare's respite care payment per day, not to exceed
Part A inpatient deductible ($1,340 FY 2018)
•Daily rate is not related to amount of services
•Payment for a day with no services is equal to a day with many services
•Daily rate does not include costs of services unrelated to terminal illness (Medicare
Part A and B, as applicable)
ambulatory surgical center (ASC) - ANSWER-designated surgical services to Medicare
beneficiaries, under part b, must be medicare certified.
-Medicare makes a single payment to ASCs for covered surgical procedure, including
ASC facility services furnished in connection with the covered procedure
List three items not included in ASC payments for covered surgical procedure or
covered ancillary services: - ANSWER-Physicians' Services
Ambulance Services
Non-Implantable Prosthetic Devices
, Under the ASC PPS Medicare payment equal ____ percent and the beneficiary
copayment equals ___ of the total reimbursement for services provided - ANSWER-
80/20
Under the ASC List multiple procedures performed during the same surgical session are
reimbursed at which of the following rate? - ANSWER-The procedure in the highest
APC receives full payment and the remaining procedures receive half (50%) payment.
ambulatory surgical center (ASC) PPS - ANSWER-uses HCPCS coding system,
payment based on APC group relative weight.
ASCs are used for the following cases. - ANSWER-Outpatient (typically) cases up to
Acuity Level III
•Non-emergent cases
•Almost every specialty except cardio and
neurology
Medicare-certified ASCs must accept assignment, meaning? - ANSWER-An ASC must
accept Medicare payment as payment in full
ASC PPS codes? - ANSWER-HCPCS Level I and II
Federally Qualified Health Centers (FQHC PPS) - ANSWER-Medicare reimbursement
system implemented in 2014 to compensate federally qualified health centers according
to a prospectively established base rate for geographic locality and patients'
characteristics.
What are the two types of reimbursement systems - ANSWER-Fee-for-service and
episode-of-care
fee for service system - ANSWER-a system under which doctors and hospitals receive
a payment for each service they provide
episode of care system - ANSWER-covers all the care a patient receives in the course
of treatment for a specific illness, condition or medical event
3 examples of Fee-for-service - ANSWER-Self pay, retrospective payment, managed
care
3 examples of episode-of-care - ANSWER-Managed care capitation, global payment,
prospective payment
Characteristics of HMOs - ANSWER-Entity that combines the provision of healthcare
insurance and the delivery of healthcare services.
Characterized by
