Reimbursement Methodologies Exam
with Complete Solutions
Accept Assignment - ANS-A term used to refer to a provider's or a supplier's
acceptance of the allowed charges (from a fee schedule) as payment in full for services
or materials provided
Accounts Receivable - ANS-Records of payments owed to the organization by outside
entities such as third-party payers and patients
Acute Care Prospective Payment System (PPS) - ANS-The reimbursement system for
inpatient hospital services provided to Medicare and Medicaid beneficiaries that is
based on the use of diagnosis-related groups as a classification tool
Administrative Services Only (ASO) Contracts - ANS-An agreement between an
employer and an insurance organization to administer the employer's self-insured health
plan
Advance Beneficiary Notice (ABN) - ANS-A statement signed by the patient when he or
she is notified by the provider, prior to a service or procedure being done, that Medicare
may not reimburse the provider for the service, wherein the patient indicates that he will
be responsible for any charges
All Patient DRGs (AP-DRGs) - ANS-A case-mix system developed by 3M and used in a
number of state reimbursement systems to classify non-Medicare discharges for
reimbursement purposes
All Patient Refined DRGs (APR-DRGs) - ANS-An expansion of the inpatient
classification system that includes four distinct sub-classes (minor, moderate, major,
and extreme) based on the severity of the patient's illness
Ambulatory Payment Classification (APC) System - ANS-The prospective payment
system used since 2000 for reimbursement of hospitals for outpatient services provided
to Medicare and Medicaid beneficiaries
Ambulatory Surgery Center (ASC) - ANS-Under Medicare, an outpatient surgical facility
that has its own national identifier; is a separate entity with respect to its licensure,
accreditation, governance, professional supervision, administrative functions, clinical
services, record keeping, and financial and accounting systems; has as its sole purpose
the provision of services in connection with surgical procedures that do not require
, inpatient hospitalization; and meets the conditions and requirements set forth in the
Medicare Conditions of Participation
Ambulatory Surgery Center Prospective Payment System (ASC PPS) - ANS-The
system that resulted from the Medicare Modernization Act (MMA) of 2003 extensively
revising the ASC payment system with changes going into effect on January 1, 2008
Automated Code Assignment - ANS-Uses data that have been entered into a computer
to automatically assign codes; uses natural language processing (NLP) technology-
algorithmic (rules based) or statistical- to read the data contained in a CPR
Balance Billing - ANS-A reimbursement method that allows providers to bill patients for
charges in excess of the amount paid by the patient' health plan or other third-party
payer (not allowed under Medicare or Medicaid)
Balanced Budget Refinement Act (BBRA) - ANS-Authorizes implementation of a per-
discharge prospective payment system for care provided to Medicare beneficiaries by
inpatient rehabilitation facilities
Blue Cross and Blue Shield (BC/BS) - ANS-The first prepaid healthcare plans in the
United States; Blue Shield plans traditionally cover hospital care and Blue Cross plans
cover physicians' services
Blue Cross and Blue Shield Federal Employee Program (FEP) - ANS-A federal program
that offers a fee-for-service plan with preferred provider organizations and a point-of-
service product
Fee-For-Service Basis - ANS-A reimbursement method involving third-party payers who
compensate providers after the healthcare services have been delivered; payment is
based on specific services provided to subscribers
Fiscal Intermediary (FI) - ANS-An organization that contracts with the Centers for
Medicare and Medicaid Services to serve as the financial agent between providers and
the federal government in the local administration of Medicare Part B claims
Fraud and Abuse - ANS-The intentional and mistaken misrepresentation of
reimbursement claims submitted to government-sponsored health programs
Geographic Practice Cost Index (GPCI) - ANS-An index developed by CMS to measure
the differences in resource costs among fee schedule areas compared to the national
average in the three components of the relative value unit; physician work, practice
expenses, and malpractice coverage
Global Payment - ANS-A form of reimbursement used for radiological and other
procedures that combines the professional and technical components of the procedures
with Complete Solutions
Accept Assignment - ANS-A term used to refer to a provider's or a supplier's
acceptance of the allowed charges (from a fee schedule) as payment in full for services
or materials provided
Accounts Receivable - ANS-Records of payments owed to the organization by outside
entities such as third-party payers and patients
Acute Care Prospective Payment System (PPS) - ANS-The reimbursement system for
inpatient hospital services provided to Medicare and Medicaid beneficiaries that is
based on the use of diagnosis-related groups as a classification tool
Administrative Services Only (ASO) Contracts - ANS-An agreement between an
employer and an insurance organization to administer the employer's self-insured health
plan
Advance Beneficiary Notice (ABN) - ANS-A statement signed by the patient when he or
she is notified by the provider, prior to a service or procedure being done, that Medicare
may not reimburse the provider for the service, wherein the patient indicates that he will
be responsible for any charges
All Patient DRGs (AP-DRGs) - ANS-A case-mix system developed by 3M and used in a
number of state reimbursement systems to classify non-Medicare discharges for
reimbursement purposes
All Patient Refined DRGs (APR-DRGs) - ANS-An expansion of the inpatient
classification system that includes four distinct sub-classes (minor, moderate, major,
and extreme) based on the severity of the patient's illness
Ambulatory Payment Classification (APC) System - ANS-The prospective payment
system used since 2000 for reimbursement of hospitals for outpatient services provided
to Medicare and Medicaid beneficiaries
Ambulatory Surgery Center (ASC) - ANS-Under Medicare, an outpatient surgical facility
that has its own national identifier; is a separate entity with respect to its licensure,
accreditation, governance, professional supervision, administrative functions, clinical
services, record keeping, and financial and accounting systems; has as its sole purpose
the provision of services in connection with surgical procedures that do not require
, inpatient hospitalization; and meets the conditions and requirements set forth in the
Medicare Conditions of Participation
Ambulatory Surgery Center Prospective Payment System (ASC PPS) - ANS-The
system that resulted from the Medicare Modernization Act (MMA) of 2003 extensively
revising the ASC payment system with changes going into effect on January 1, 2008
Automated Code Assignment - ANS-Uses data that have been entered into a computer
to automatically assign codes; uses natural language processing (NLP) technology-
algorithmic (rules based) or statistical- to read the data contained in a CPR
Balance Billing - ANS-A reimbursement method that allows providers to bill patients for
charges in excess of the amount paid by the patient' health plan or other third-party
payer (not allowed under Medicare or Medicaid)
Balanced Budget Refinement Act (BBRA) - ANS-Authorizes implementation of a per-
discharge prospective payment system for care provided to Medicare beneficiaries by
inpatient rehabilitation facilities
Blue Cross and Blue Shield (BC/BS) - ANS-The first prepaid healthcare plans in the
United States; Blue Shield plans traditionally cover hospital care and Blue Cross plans
cover physicians' services
Blue Cross and Blue Shield Federal Employee Program (FEP) - ANS-A federal program
that offers a fee-for-service plan with preferred provider organizations and a point-of-
service product
Fee-For-Service Basis - ANS-A reimbursement method involving third-party payers who
compensate providers after the healthcare services have been delivered; payment is
based on specific services provided to subscribers
Fiscal Intermediary (FI) - ANS-An organization that contracts with the Centers for
Medicare and Medicaid Services to serve as the financial agent between providers and
the federal government in the local administration of Medicare Part B claims
Fraud and Abuse - ANS-The intentional and mistaken misrepresentation of
reimbursement claims submitted to government-sponsored health programs
Geographic Practice Cost Index (GPCI) - ANS-An index developed by CMS to measure
the differences in resource costs among fee schedule areas compared to the national
average in the three components of the relative value unit; physician work, practice
expenses, and malpractice coverage
Global Payment - ANS-A form of reimbursement used for radiological and other
procedures that combines the professional and technical components of the procedures
