Healthcare Reimbursement Study Guide
with Questions and Correct Answers
What are the two types of reimbursement systems ✅Fee-for-service and episode-of-
care
fee-for-service ✅a system under which doctors and hospitals receive a payment for
each service they provide
Episode-of care ✅Payment based on services provided for conditions for which the
patient is treated.
3 examples of Fee-for-service ✅Self pay, retrospective payment, managed care
3 examples of episode-of-care ✅Managed care capitation, global payment,
prospective payment
Self pay ✅Patients without third-party payer coverage or restrictive coverage pay on a
Fee-for-service basis
Affordable Care Act (ACA) ✅ObamaCare (the Affordable Care Act) is a US healthcare
reform law that expands and improves access to care and curbs spending through
regulations and taxes.
medical loss ratio (MLR) ✅A basic financial measurement used in the Affordable Care
Act to encourage health plans to provide value to enrollees. If an insurer uses 80 cents
out of every premium dollar to pay its customers' medical claims and activities that
improve the quality of care, the company has a medical loss ratio of 80%.
(MHPAEA) Mental Health Parity and Addiction Equity Act 2008 ✅Law that prevents
health plans and health insurers providing mental health or substance use disorders
benefits from imposing less favorable benefit limitations on those benefits than on
medical or surgical benefits.
Minimal essential coverage (MEC) ✅Level of coverage an individual needs to have to
meet the individual responsibility requirements under the affordable care act.
Patient's/Residents Bill of Rights ✅Set of protections that will help Americans with pre
existing conditions gain and keep their coverage, protects Americans choice of doctors,
ends lifetime limits on the care consumers may receive and includes other provisions?
, Retrospective payment system ✅Payment made based on services rendered ( what
was done not what was wrong or how long the patient was treated) A fee-for-service
that is reimbursed to the provider after health services have been provided.
Third-party fee schedules ✅Third party fee schedules are a predetermined list of
maximum allowable fees for specific healthcare services.
Explanation of Benefits (EOB) ✅Document or report sent to the policyholder and the
provider by the insurer describing the healthcare services, the cost, applicable cost
sharing and the amount the insurer will cover.
Usual Customary and Reasonable (UCR) ✅Amount paid for a medical service in a
geographic area based on what providers in the area usually charge for the same or
similar medical services. Rates are set by third-party payers based on historical data for
a given geographical area or medical specialty.
Resource Based Relative Value Scale (RBRVS) ✅Retrospective based methodology
used by Medicare to determine reimbursement amounts for physician based services.
(RBRVS) seeks to set rates for physicians services based on what primary 3 factors?
✅Physicians work (effort), practice expense (overhead) and professional liability
(malpractice insurance)
Relative Value Unit (RVU) ✅Is a unit of weight assigned to each factor in the (RBRVS)
which is multiplied by a dollar amount supplied by the (CMS). Payments are adjusted by
geographical differences.
procedure code ✅A code that identifies a medical service and procedures
Managed Care Plans ✅Operates under either a fee-for-service or episode-of-care
model. Simply means the third-party payer takes an active role in influencing cost and
quality through its policies and provisions. Ex: preauthorizations allow third-party payers
to influence decisions by requiring second opinions or conservative therapy first.
Health maintenance organizations (HMO's) ✅Exercise the most control over patient
choice and provider treatment options. To obtain maximum benefits one must choose a
(PCP), obtain referrals for specialists and various types of procedures.
case management ✅Structure in (HMO's) in which certain illnesses i.e.: cancer,
diabetes, asthma are assigned a case manager to coordinate patient care reducing
overlapping care and duplicate treatment.
Preferred Provider Organization (PPO) ✅Less restrictive type of managed care. Third
part-payer contracts with healthcare providers for discounted rates. Patient who elect to
with Questions and Correct Answers
What are the two types of reimbursement systems ✅Fee-for-service and episode-of-
care
fee-for-service ✅a system under which doctors and hospitals receive a payment for
each service they provide
Episode-of care ✅Payment based on services provided for conditions for which the
patient is treated.
3 examples of Fee-for-service ✅Self pay, retrospective payment, managed care
3 examples of episode-of-care ✅Managed care capitation, global payment,
prospective payment
Self pay ✅Patients without third-party payer coverage or restrictive coverage pay on a
Fee-for-service basis
Affordable Care Act (ACA) ✅ObamaCare (the Affordable Care Act) is a US healthcare
reform law that expands and improves access to care and curbs spending through
regulations and taxes.
medical loss ratio (MLR) ✅A basic financial measurement used in the Affordable Care
Act to encourage health plans to provide value to enrollees. If an insurer uses 80 cents
out of every premium dollar to pay its customers' medical claims and activities that
improve the quality of care, the company has a medical loss ratio of 80%.
(MHPAEA) Mental Health Parity and Addiction Equity Act 2008 ✅Law that prevents
health plans and health insurers providing mental health or substance use disorders
benefits from imposing less favorable benefit limitations on those benefits than on
medical or surgical benefits.
Minimal essential coverage (MEC) ✅Level of coverage an individual needs to have to
meet the individual responsibility requirements under the affordable care act.
Patient's/Residents Bill of Rights ✅Set of protections that will help Americans with pre
existing conditions gain and keep their coverage, protects Americans choice of doctors,
ends lifetime limits on the care consumers may receive and includes other provisions?
, Retrospective payment system ✅Payment made based on services rendered ( what
was done not what was wrong or how long the patient was treated) A fee-for-service
that is reimbursed to the provider after health services have been provided.
Third-party fee schedules ✅Third party fee schedules are a predetermined list of
maximum allowable fees for specific healthcare services.
Explanation of Benefits (EOB) ✅Document or report sent to the policyholder and the
provider by the insurer describing the healthcare services, the cost, applicable cost
sharing and the amount the insurer will cover.
Usual Customary and Reasonable (UCR) ✅Amount paid for a medical service in a
geographic area based on what providers in the area usually charge for the same or
similar medical services. Rates are set by third-party payers based on historical data for
a given geographical area or medical specialty.
Resource Based Relative Value Scale (RBRVS) ✅Retrospective based methodology
used by Medicare to determine reimbursement amounts for physician based services.
(RBRVS) seeks to set rates for physicians services based on what primary 3 factors?
✅Physicians work (effort), practice expense (overhead) and professional liability
(malpractice insurance)
Relative Value Unit (RVU) ✅Is a unit of weight assigned to each factor in the (RBRVS)
which is multiplied by a dollar amount supplied by the (CMS). Payments are adjusted by
geographical differences.
procedure code ✅A code that identifies a medical service and procedures
Managed Care Plans ✅Operates under either a fee-for-service or episode-of-care
model. Simply means the third-party payer takes an active role in influencing cost and
quality through its policies and provisions. Ex: preauthorizations allow third-party payers
to influence decisions by requiring second opinions or conservative therapy first.
Health maintenance organizations (HMO's) ✅Exercise the most control over patient
choice and provider treatment options. To obtain maximum benefits one must choose a
(PCP), obtain referrals for specialists and various types of procedures.
case management ✅Structure in (HMO's) in which certain illnesses i.e.: cancer,
diabetes, asthma are assigned a case manager to coordinate patient care reducing
overlapping care and duplicate treatment.
Preferred Provider Organization (PPO) ✅Less restrictive type of managed care. Third
part-payer contracts with healthcare providers for discounted rates. Patient who elect to
