HIS 123 Quiz 1
Define resource intensity
Demand and costs associated with treating specific types of patients
Medicaid is provided for?
Funding for health care for low-income individuals. Shared federal and state resource; shifts resources from high - income to lower - income individuals
ALOS for LTC patients
Greater than 25 days
The APC uses what to group patients?
HCPCS/CPT procedure, service, or item codes
What managed care organization has ownership or employer control over the healthcare provider?
HMO's
What does HMO stand for?
Health Maintenance Organization
OASIS data set is used in what type of setting
Home Health Care
Managed care refers to:
Insurer focused on reducing health care cost, controlling expensive care, improving quality of patient care.
What title are Medicare and Medicaid under and what year where they established?
Medicare Title XVIII - 1965 Medicaid Title XIX - 1965
Define Indemnity Insurance
Assumption of payment for all or part of certain specified services. Characterized by out of pocket deductibles and caps on total covered payments
Explain Relative Weight (RW)
National Numeric Value assigned yearly by CMS that is applied to each DRG and used to calculate reimbursement
NUBC Stands for?
National Uniform Billing Committee
Medicare covers what type of patient?
Older adults, individuals with certain disabilities; early stage renal disease (ESRD) and kidney transplantation
Explain fiscal Intermediaries:
Organizations that administer the claims and reimbursement of the funding agency.
Define capitation
Requires payment to a healthcare provider regardless of whether the patient is seen or how frequently the patient is seen during a given period. Uniform reimbursement is based on number of patients contractually in physicians care.
RAI Stands For
Resident Assessment Instrument
What is NUBC responsible for?
Responsible for developing and maintaining the UB-04 Claim Bill
Explain PRO's (Peer Review Organizations)
Reviewed Medicare and Medicaid cases to ensure only medically necessary services are being rendered.
The federal law that replaces PSRO's with PRO's is?
TEFRA
Pertaining to Managed care a patient sees a primary care physician, this person is also called:
The Gatekeeper; PCP and Participating Provider
Define principal diagnosis
The condition that, after study, is determined to be chiefly responsible for occasioning the admission of the patient to the hospital for care
Guarantor
The person ultimately responsible for paying the provider
Define Modifier
Two digit number added to HCPCS/CPT code that provides additional information regarding procedure or service performed
U and C stand for?
Usual and Customary
UR stands for
Utilization Review
Usual and Customary Fees
What type of reimbursement is compared based on a particular state or geographic location and ignores the very high and low fees.
Attending Physician
Who is responsible for patients overall care while in the hospital
Case Mix Index (CMI) is published
Yearly by CMS and hospital has own unique provider number
Explain self-insurance
Alternative to insurance - Organization or Individual can set aside funds thru payroll to cover cost of employee health care.
IHS (indian health services) provides care for:
American Indians, Alaskan Natives
What is a wrap-around policy?
Insurance policy that supplements Medicare coverage; also called secondary insurance
Utilization Review tasks are?
Admission Denial; Discharge Planning; Continued Stay Denial
Explain Revenue Cycle Management
All activities that connect the services being rendered to a patient with the providers reimbursement for those services
What is Revenue code?
3 digit code that denotes the department in which a procedure, service or supply item was provided
Co-payment
A fixed amount paid by the patient at the time of service is called?
What is deductible?
A specified dollar amount which must be incurred for services by the patient before the payer reimburses. Patient is responsible for this amt.
OPPS uses what classification system for Medicare outpatient services for the basis of reimbursement?
APC's - Ambulatory Payment Classifications
Who administers Medicare?
CMS - Centers for Medicare/Medicaid Services
What was Tricare formerly called?
Champus
What is HMO characterized by?
Characterized by the ownership or employer control over health care providers.
What is the systematic collection of specific charges for services rendered to a patient?
Charge Capture
Define C&C
Co-morbidity - Co-existing sickness or disease Complication - Condition that arose during hospitalization; CC's are only secondary diagnoses
CC stand for
Co-morbidity and Complication
Explain PPO (Preferred Provider Organization)
Contracts with a network of healthcare providers who agree to certain reimbursement rates
What is PPS (Prospective Payment System) based on?
DRG Classification system
What is per diem?
Daily - flat fee negotiated in advance for inpatient services
Define clincial pathway:
Discipline-specific - Appropriate steps to take; given a specific diagnosis or signs and symptoms
Continued Stay Denial:
If additional days in a facility not justified by documentation, the additional days may not be reimbursed by insurance
What is an admission denial?
If the admission is found unnecessary then Utilization review staff members would not certify the admission for reimbursement.
Insurance types fall into two basic categories:
Indemnity and Managed Care
Explain what MCE stands for:
List of codes that would not make sense as a principal diagnosis in an acute care facility - Medicare Code Editor
Define LCD
List of diagnostic codes used by Medicare contractors to determine medical necessity
What does LCD stand for?
Local Coverage determination
what does MDC stand for?
Major Diagnostic Categories
Who is the payer?
Party from whom the provider is expecting payment. Frequently and insurance company, may also be a government agency.
Define MDC
Patients are assigned into basic sections primarily by body systems
What is reimbursement?
Payment provided to health care provider in exchange for services rendered.
Define co-insurance
Percent of payment for which patient is responsible
Utilization Review is responsible for what 4 things?
Performs admission review; Monitors intensity of services provided; Ensured patients LOS is appropriate for level of care; Will not certify admission if found unnecessary
explain U&C
Pertaining to regional charges for particular services
Explain what Group Plan is:
Pool of covered individuals - averages risk for that 3rd party payer, lowers premiums for groups as a whole
Explain Health Saving Account:
Provides the individual with a savings acct, usually thru payroll deduction, into which a set amount determined by the employee can be deposited routinely
RAI are used in what setting
Skilled Nursing Facility (SNF))
Charges are captured in the ambulatory setting on what type of form?
Superbill/Encounter Form
