Reimbursement Methodologies
Content Area Exam-Graded A
A) - ANS-The Health Insurance Portability and Accountability Act (HIPAA) requires the
retention of health insurance claims and accounting records for a minimum of
_________years, unless state law specifies a longer period
A) six
B) five
C) seven
D) ten
D - ANS-In a global payment methodology, which is sometimes applied to radiological
and similar types of procedures that involve professional and technical components, all
of the following are part of the "technical" components EXCEPT
A) radiological equipment
B) physician services
C) radiological supplies
D) support services
A - ANS-All of the following statements are true of MS-DRGs, EXCEPT
A) a patient claim may have multiple MS-DRGs.
B) the MS-DRG payment received by the hospital may be lower than the actual cost of
providing the services
C) special circumstances can result in an outlier payment to the hospital
D) there are several types of hospitals that are excluded from the Medicare inpatient
PPS
D - ANS-Under ASCs, bilateral procedures are reimbursed at _____ of the payment rate
for their group
A) 50%
B) 100%
C) 200%
D) 150%
A - ANS-In the managed care industry, there are specific reimbursement concepts, such
as "capitation." All of the following statements are true in regard to the concept of
"capitation," EXCEPT
,A) each service is paid based on the actual charges
B) the volume of services and their expense do not affect reimbursement
C) capitation means paying a fixed amount per member per month
D) capitation involves a group of physicians or an individual physician
A - ANS-________ is an act that represents a crime against payers or other health care
programs (e.g., Medicare), or attempts or conspiracies to commit those crimes.
A) Fraud
B) Whistle-blowing
C) Abuse
D) Assault
C - ANS-The case-mix management system that utilizes information from the Minimum
Data Set (MDS) in long-term care settings is called
A) Medicare Severity Diagnosis Related Groups (MS-DRGs)
B) Resource Based Relative Value System (RBRVS)
C) Resource Utilization Groups (RUGs)
D) Ambulatory Patient Classifications (APCs)
Y - ANS-A patient undergoes outpatient surgery. During the recovery period, the patient
develops atrial fibrillation and is subsequently admitted to the hospital as an inpatient.
The present on admission (POA) indicator is
Y = present at the time of inpatient admission
N = not present at the time of inpatient admission
U = documentation is insufficient to determine if condition was present at the time of
admission
W = provider is unable to clinically determine if condition was present at the time of
admission
C - ANS-Currently, which prospective payment system is used to determine the
payment to the physician for outpatient surgery performed on a Medicare patient?
A) MS-DRGs
B) APGs
C) RBRVS
D) ASCs
- ANS-Under APCs, payment status indicator "V" means
A) ancillary servicessignificant procedure, not discounted when multiple.
, B) clinic or emergency department visit (medical visits)inpatient procedure.
c. ancillary services.
d. clinic or emergency department visit (medical visits).
A) $66.50
If a physician is a nonparticipating physician who does not accept assignment, he may
collect a maximum of 15% (the limiting charge) over the non-PAR Medicare fee
schedule amount.
$190.00 = non-PAR Medicare schedule amount
$190.00 x 0.20 = $38.00 = patient liable for 20% coinsurance (patient previously met the
deductible)
$190.00 x 0.80 = $152.00 = Medicare pays 80%
$190.00 x 0.15 = $28.50 = 15% (limiting charge) over non-PAR Medicare fee schedule
amount
Physician can balance bill and collect from the patient the difference between the non-
PAR
Medicare fee schedule amount and the total charge amount. Therefore, the patient's
financial liability is $38.00 (coinsurance) + 28.50 (limiting charge) = $66.50. - ANS-A
patient with Medicare is seen in the physician's office. The total charge for this office
visit is $250.00. The patient has previously paid his deductible under Medicare Part B.
The PAR Medicare fee schedule amount for this service is $200.00. The nonPAR
Medicare fee schedule amount for this service is $190.00.
If this physician is a nonparticipating physician who does NOT accept assignment for
this claim, the total amount of the patient's financial liability (out-of-pocket expense) is
A. $66.50.
B. $38.00.
C. $190.00.
D. $152.00.
D skilled nursing facilities - ANS-The prospective payment system based on resource
utilization groups (RUGs) is used for reimbursement to ________ for patients with
Medicare.
A. freestanding ambulatory surgery centers
B. hospital-based outpatients
C. intermediate care facilities
D. skilled nursing facilities
REFERENCE:
Schraffenberger and Kuehn, p 212
Content Area Exam-Graded A
A) - ANS-The Health Insurance Portability and Accountability Act (HIPAA) requires the
retention of health insurance claims and accounting records for a minimum of
_________years, unless state law specifies a longer period
A) six
B) five
C) seven
D) ten
D - ANS-In a global payment methodology, which is sometimes applied to radiological
and similar types of procedures that involve professional and technical components, all
of the following are part of the "technical" components EXCEPT
A) radiological equipment
B) physician services
C) radiological supplies
D) support services
A - ANS-All of the following statements are true of MS-DRGs, EXCEPT
A) a patient claim may have multiple MS-DRGs.
B) the MS-DRG payment received by the hospital may be lower than the actual cost of
providing the services
C) special circumstances can result in an outlier payment to the hospital
D) there are several types of hospitals that are excluded from the Medicare inpatient
PPS
D - ANS-Under ASCs, bilateral procedures are reimbursed at _____ of the payment rate
for their group
A) 50%
B) 100%
C) 200%
D) 150%
A - ANS-In the managed care industry, there are specific reimbursement concepts, such
as "capitation." All of the following statements are true in regard to the concept of
"capitation," EXCEPT
,A) each service is paid based on the actual charges
B) the volume of services and their expense do not affect reimbursement
C) capitation means paying a fixed amount per member per month
D) capitation involves a group of physicians or an individual physician
A - ANS-________ is an act that represents a crime against payers or other health care
programs (e.g., Medicare), or attempts or conspiracies to commit those crimes.
A) Fraud
B) Whistle-blowing
C) Abuse
D) Assault
C - ANS-The case-mix management system that utilizes information from the Minimum
Data Set (MDS) in long-term care settings is called
A) Medicare Severity Diagnosis Related Groups (MS-DRGs)
B) Resource Based Relative Value System (RBRVS)
C) Resource Utilization Groups (RUGs)
D) Ambulatory Patient Classifications (APCs)
Y - ANS-A patient undergoes outpatient surgery. During the recovery period, the patient
develops atrial fibrillation and is subsequently admitted to the hospital as an inpatient.
The present on admission (POA) indicator is
Y = present at the time of inpatient admission
N = not present at the time of inpatient admission
U = documentation is insufficient to determine if condition was present at the time of
admission
W = provider is unable to clinically determine if condition was present at the time of
admission
C - ANS-Currently, which prospective payment system is used to determine the
payment to the physician for outpatient surgery performed on a Medicare patient?
A) MS-DRGs
B) APGs
C) RBRVS
D) ASCs
- ANS-Under APCs, payment status indicator "V" means
A) ancillary servicessignificant procedure, not discounted when multiple.
, B) clinic or emergency department visit (medical visits)inpatient procedure.
c. ancillary services.
d. clinic or emergency department visit (medical visits).
A) $66.50
If a physician is a nonparticipating physician who does not accept assignment, he may
collect a maximum of 15% (the limiting charge) over the non-PAR Medicare fee
schedule amount.
$190.00 = non-PAR Medicare schedule amount
$190.00 x 0.20 = $38.00 = patient liable for 20% coinsurance (patient previously met the
deductible)
$190.00 x 0.80 = $152.00 = Medicare pays 80%
$190.00 x 0.15 = $28.50 = 15% (limiting charge) over non-PAR Medicare fee schedule
amount
Physician can balance bill and collect from the patient the difference between the non-
PAR
Medicare fee schedule amount and the total charge amount. Therefore, the patient's
financial liability is $38.00 (coinsurance) + 28.50 (limiting charge) = $66.50. - ANS-A
patient with Medicare is seen in the physician's office. The total charge for this office
visit is $250.00. The patient has previously paid his deductible under Medicare Part B.
The PAR Medicare fee schedule amount for this service is $200.00. The nonPAR
Medicare fee schedule amount for this service is $190.00.
If this physician is a nonparticipating physician who does NOT accept assignment for
this claim, the total amount of the patient's financial liability (out-of-pocket expense) is
A. $66.50.
B. $38.00.
C. $190.00.
D. $152.00.
D skilled nursing facilities - ANS-The prospective payment system based on resource
utilization groups (RUGs) is used for reimbursement to ________ for patients with
Medicare.
A. freestanding ambulatory surgery centers
B. hospital-based outpatients
C. intermediate care facilities
D. skilled nursing facilities
REFERENCE:
Schraffenberger and Kuehn, p 212
