CCM-HEALTHCARE REIMBURSEMENT/MANAGEMENT
EXAM WITH ALL CORRECT & 100% VERIFIED ANSWERS
|ALREADY GRADED A+
Hard Savings ✔Correct Answer-dollars to the bottom line that are realized now
Soft Savings ✔Correct Answer-dollars that may contribute to the bottom line in the future
Medicare
To be eligible for Medicare, an individual must:
Be 65 years of age or older OR have a qualified disability
Be a U. S. citizen or legal resident for at least 5 consecutive years ✔Correct Answer-Eligibility for
Medicare on the basis of disability begins after an individual has been entitled to Social Security
disability benefits for 24 months. There is a 5-month waiting period before an individual begins to
receive Social Security disability payments.
This means that, in most instances, there will be a 29-month period before the individual becomes
entitled to Medicare.
Medicaid
Federally funded healthcare program 1964; Title XIX of the Social Security Act. Is part of the federal
and state welfare systems. ✔Correct Answer-Although the federal government establishes the
general guidelines, the actual requirements are established by each state. Medicaid programs are
subject to state regulatory agencies; therefore, wide variations to coverage and eligibility exist
among the different states.
Medicaid is always the "payer of the last resort."
Medicare will cover a SNF stay ✔Correct Answer-A hospital stay of at least 3 days is needed prior
to SNF admission and 30 days from D/C.
Medicare pays 100% for first 20 days then 80% up to a total of 100 days.
The needs to be admission free for 60 day before a new benefit period starts.
Minimum data set (MDS)
refers to the standardized, primary screening and assessment tool of health status that is part of a
comprehensive assessment required for all residents in a Medicare and/or Medicaid-certified long-
term care facilitiy. ✔Correct Answer-It gives a multidimensional view of the patient's functional
capacities and helps staff to identify health issues. The MDS is also used as part of the Medicare
reimbursement process as it determines resource utilization group (RUG) category for each patient;
RUGs are used to determine reimbursement rates for the facility.
O2 sats level needed for Medicare to approve home oxygen ✔Correct Answer-Levels must be no
higher than 88% for Medicare to approve home oxygen
OASIS ✔Correct Answer-Outcome and Assessment Information Set. Any home health agency
wishing to seek reimbursement from Medicare for home care services must submit bill with an OASIS
form.
, HEDIS
Health Plan Employer Data and Information Set
• A performance measurement for managed care
• Focuses on the quality of the system, process, & services offered by the plan to enrollees.
• Access to services & effectiveness of care
• Developed by National Commission on Quality Assurance (NCQA) ✔Correct Answer-• Data
available to consumers and providers
• Includes effectiveness of & access to care; consumer satisfaction; cost; utilization; and credentialing
of providers
POS ✔Correct Answer-Point of Service
• Plan that allows a participant to choose any provider; typically there are higher costs in premiums,
deductibles and coinsurance
coinsurance ✔Correct Answer-is the portion of the cost of a healthcare service that the patient is
responsible for paying.
reinsurance ✔Correct Answer-is insurance that is purchased by an insurance company (the ceding
company) from one or more insurance companies (reinsurer)either directly or through a broker as a
means of risk management. The reinsurance agreement details conditions upon which the reinsurer
will pay a share of claims incurred by the ceding company. The ceding company pays a resinsurance
premium to the reinsurer.
PPO ✔Correct Answer-is a managed care organization of medical doctors, hospitals, and other
healthcare providers who have agreed with an insurer or third-party administrator to provide health
care at reduced rates to the insurer's or administrator's clients.
• PPOs are reimbursed through DRGs
DRGs ✔Correct Answer-diagnosis related groups are rates of reimbursement for particular
categories of services. This may be a pay rate for facility fees for care and services, or a specific dollar
amount that is paid for classification of illnesses, a diagnosis, or procedure. The concept of DRGs
came about as a result of the development of health maintenance organizations (HMOs) and
prospective payment systems (PPS).
self-insurance ✔Correct Answer-is a risk management method in which a calculated amount of
money is set aside to compensate for potential future loss. Self-funded health care is a self-insurance
arrangement whereby an employer provides health or disability benefits to employees with its own
funds.
PPS
Prospective Payment Systems
• A system of payment by which healthcare services provided through inpatient, sub-acute care,
long-term care, skilled nursing and rehabilitation facilities, and home care are reimbursed according
to pre-determined reimbursement rates. ✔Correct Answer-• PPS in the inpatient setting - DRGs
• PPS in ambulatory care - ambulatory payment classification (APC)
• PPS in rehabilitation setting - case mix groups (CMGs)
• PPS in SNF - resource utilization group (RUG) (questions seen on this!)
• PPS in HHC - home health resource groups (HHRGs
PPS in SNF ✔Correct Answer-RUG-resource utilization group
EXAM WITH ALL CORRECT & 100% VERIFIED ANSWERS
|ALREADY GRADED A+
Hard Savings ✔Correct Answer-dollars to the bottom line that are realized now
Soft Savings ✔Correct Answer-dollars that may contribute to the bottom line in the future
Medicare
To be eligible for Medicare, an individual must:
Be 65 years of age or older OR have a qualified disability
Be a U. S. citizen or legal resident for at least 5 consecutive years ✔Correct Answer-Eligibility for
Medicare on the basis of disability begins after an individual has been entitled to Social Security
disability benefits for 24 months. There is a 5-month waiting period before an individual begins to
receive Social Security disability payments.
This means that, in most instances, there will be a 29-month period before the individual becomes
entitled to Medicare.
Medicaid
Federally funded healthcare program 1964; Title XIX of the Social Security Act. Is part of the federal
and state welfare systems. ✔Correct Answer-Although the federal government establishes the
general guidelines, the actual requirements are established by each state. Medicaid programs are
subject to state regulatory agencies; therefore, wide variations to coverage and eligibility exist
among the different states.
Medicaid is always the "payer of the last resort."
Medicare will cover a SNF stay ✔Correct Answer-A hospital stay of at least 3 days is needed prior
to SNF admission and 30 days from D/C.
Medicare pays 100% for first 20 days then 80% up to a total of 100 days.
The needs to be admission free for 60 day before a new benefit period starts.
Minimum data set (MDS)
refers to the standardized, primary screening and assessment tool of health status that is part of a
comprehensive assessment required for all residents in a Medicare and/or Medicaid-certified long-
term care facilitiy. ✔Correct Answer-It gives a multidimensional view of the patient's functional
capacities and helps staff to identify health issues. The MDS is also used as part of the Medicare
reimbursement process as it determines resource utilization group (RUG) category for each patient;
RUGs are used to determine reimbursement rates for the facility.
O2 sats level needed for Medicare to approve home oxygen ✔Correct Answer-Levels must be no
higher than 88% for Medicare to approve home oxygen
OASIS ✔Correct Answer-Outcome and Assessment Information Set. Any home health agency
wishing to seek reimbursement from Medicare for home care services must submit bill with an OASIS
form.
, HEDIS
Health Plan Employer Data and Information Set
• A performance measurement for managed care
• Focuses on the quality of the system, process, & services offered by the plan to enrollees.
• Access to services & effectiveness of care
• Developed by National Commission on Quality Assurance (NCQA) ✔Correct Answer-• Data
available to consumers and providers
• Includes effectiveness of & access to care; consumer satisfaction; cost; utilization; and credentialing
of providers
POS ✔Correct Answer-Point of Service
• Plan that allows a participant to choose any provider; typically there are higher costs in premiums,
deductibles and coinsurance
coinsurance ✔Correct Answer-is the portion of the cost of a healthcare service that the patient is
responsible for paying.
reinsurance ✔Correct Answer-is insurance that is purchased by an insurance company (the ceding
company) from one or more insurance companies (reinsurer)either directly or through a broker as a
means of risk management. The reinsurance agreement details conditions upon which the reinsurer
will pay a share of claims incurred by the ceding company. The ceding company pays a resinsurance
premium to the reinsurer.
PPO ✔Correct Answer-is a managed care organization of medical doctors, hospitals, and other
healthcare providers who have agreed with an insurer or third-party administrator to provide health
care at reduced rates to the insurer's or administrator's clients.
• PPOs are reimbursed through DRGs
DRGs ✔Correct Answer-diagnosis related groups are rates of reimbursement for particular
categories of services. This may be a pay rate for facility fees for care and services, or a specific dollar
amount that is paid for classification of illnesses, a diagnosis, or procedure. The concept of DRGs
came about as a result of the development of health maintenance organizations (HMOs) and
prospective payment systems (PPS).
self-insurance ✔Correct Answer-is a risk management method in which a calculated amount of
money is set aside to compensate for potential future loss. Self-funded health care is a self-insurance
arrangement whereby an employer provides health or disability benefits to employees with its own
funds.
PPS
Prospective Payment Systems
• A system of payment by which healthcare services provided through inpatient, sub-acute care,
long-term care, skilled nursing and rehabilitation facilities, and home care are reimbursed according
to pre-determined reimbursement rates. ✔Correct Answer-• PPS in the inpatient setting - DRGs
• PPS in ambulatory care - ambulatory payment classification (APC)
• PPS in rehabilitation setting - case mix groups (CMGs)
• PPS in SNF - resource utilization group (RUG) (questions seen on this!)
• PPS in HHC - home health resource groups (HHRGs
PPS in SNF ✔Correct Answer-RUG-resource utilization group
