Healthcare Reimbursement Final Exam

Which of the following is the correct format for HCPCS Level II codes?

A1234

Which of the following statements is true about APCs?

APCs are based on the CPT or HCPCS code(s) reported.

Which type of healthcare insurance policy provides benefits to an insured who is blinded as the result of an accident?

Accidental death and dismemberment insurance

Which patient registration error can appropriately be corrected by HIM coders, if permitted by policy and procedures?

Admission date

The federal government funds significant portions of which groups' healthcare?

Correct All of the above Answers: Seniors, people with disabilities, and people with end-stage renal disease Low-income persons on state Medicaid Active-duty and retired military personnel and their families and veterans Native Americans A and C only A, C, and D only Correct All of the above

In Medicare's resource-based relative value scale payment system, what is the term for the national dollar amount that is annually designated to convert relative value units into dollars?

Conversion factor

In the healthcare sector, what is the term for the fixed dollar amount that the guarantor pays?

Copayment

In Medicare's resource-based relative value scale payment system, how is the conversion factor applied?

Correct A and B only Answers: CMS annually raises or lowers the conversion factor to adjust payments for physicians and health professionals The sum of the geographically-adjusted elements of the relative value unit is multiplied by the conversion factor to arrive at the Medicare provider fee schedule CMS requires that the conversion factor be multiplied by 80% to adjust for budget neutrality Correct A and B only All of the above

What cost-sharing applies to a Medicare beneficiary who did NOT have an immediately preceding admission at an acute care hospital AND resides in an LTCH for 90 days?

Correct A and B only Answers: Inpatient deductible for the 90-day benefit period Daily coinsurance payment for days 61 through 90 Coinsurance for each lifetime reserve day Correct A and B only All of the above

CMS' analysts divide admissions to skilled nursing facilities into upper and lower categories. To which of the following categories does the "presumption of coverage" apply?

Correct A and B only Answers: Rehabilitation Plus Extensive Rehabilitation Behavioral Symptoms and Cognitive Performance Correct A and B only All of the above

What is the purpose of managed care?

Correct A and B only Answers: To reduce the costs of healthcare services To improve the quality of care for patients To leverage negotiations with state and federal agencies Correct A and B only All of the above

When comparing Medicare's IPPS and IPF PPS which of the following statement is false?

Both PPS utilize a case rate reimbursement methodology

Which of the following is/are true of CHIP?

Correct A and C are true. Answers: It is a federal/state program It is a state/local program It varies from state to state Correct A and C are true.

Which of the following payment methods are global?

Correct All of the above Answers: Block grants Surgical packages Bundling Correct All of the above

Which HIM functions affect revenue cycle management?

Correct All of the above Answers: Coding Deficiency analysis/chart completion Release of information Correct All of the above

What status characterizes medically underserved areas?

Correct All of the above Answers: High infant mortality High poverty High elderly population A and B only Correct All of the above

What are reasons why a registrar might not find the patient's previously assigned medical record number in the master patient index?

Correct All of the above Answers: Name misspelled Patient denied being there Previous registration under a different name Correct All of the above

Access to mental or behavioral health or medical specialists is through referral. What is the term for the individual who makes the referral?

Correct All of the above Answers: Primary care provider Gatekeeper Primary care physician B and C only Correct All of the above

Which Part of the Medicare program does not include a cost-sharing provision?

Correct All parts of Medicare include a cost-sharing provision. Answers: Part A Part B Part C Part D Correct All parts of Medicare include a cost-sharing provision.

True or False? For inpatient rehabilitation facility patients, codes on the IRF PAI should follow the UHDDS and the UB-04 guidelines.

False

True or False? The female worker was just married on July 1, 2016. She had worked for the organization for the past 8 years and has been covered under its group healthcare insurance policy during the entire period. She is ONLY allowed to add her new spouse during open enrollment which, for this organization, is October 1, 2016 through November 1, 2016 becoming effective on January 1, 2017.

False

What is the term for an urban, nonprofit, patient-governed, and community-directed healthcare entities receiving federal grant funding under Section 330?

Federally-qualified health centers

Which statement describes the per diem payment method?

Fixed rate for each day a covered member is hospitalized

Which of the following characteristics is representative of commercial healthcare insurances?

For-profit in the private sector

Which of the following is not a patient level adjustment used in the IPF PPS?

Full service emergency department

In an IRF, on what tool is are patients' abilities to perform activities of daily living recorded?

Functional Independence Measure (FIM) Assessment

What is the term used in a rehabilitation facility to mean "a patient's ability to perform activities of daily living"?

Functional status

All of the following specifications are types of limitations on healthcare policies except:

Geographic plan

In Medicare's resource-based relative value scale payment system, all of the factors are elements of the relative value unit except:

Geographic practice cost index

In Medicare's resource-based relative value scale payment system, which factor adjusts payments to physicians and health professionals for price differences among various parts of the country?

Geographic practice cost index

Which of the following characteristics is the greatest advantage of group healthcare insurance?

Greater benefits for lower premiums

In Medicare's prospective payment system for home health services, what classification is used to adjust for case mix?

HHRGs

How has HIPAA changed healthcare claims processing?

HIPAA requires all healthcare facilities to use standardized code sets (ICD-9-CM, CPT, and HCPCS among them) on electronic claims that contain standardized formats. This process changed the conventional submission of claims on CMS-1500 paper forms.

Which university is associated with the development of Medicare's resource-based relative value scale payment system?

Harvard

In Medicare's resource-based relative value scale payment system, to which type of code has a relative value unit been assigned?

Healthcare Common Procedure Coding System

Assuming the service is covered and medically necessary, who assumes the potential financial risk in an inpatient Medicare case?

Hospital

Which researcher is associated with Medicare's resource-based relative value scale payment system?

Hsaio

The coding system that is used primarily for reporting diagnoses for hospital inpatients is known as:

ICD-10-CM

What impact does a hospital acquired condition have on a hospital's Medicare reimbursement?

If a hospital acquired condition causes a case to be grouped to a higher paying DRG, Medicare will only reimburse for the lower paying DRG.

All of the following phenomena are considered "life events" except:

Illness

All of the following types of services or populations are common examples of "carve outs" EXCEPT:

Immunizations and well-baby care

Which of the following is not a common cause of improper payments?

Implementation of a documentation improvement program

In Medicare's prospective payment system for inpatient rehabilitation facilities, what classification is used to adjust for case mix?

In Medicare's prospective payment system for inpatient rehabilitation facilities, what classification is used to adjust for case mix?

Your hospital has an outpatient dialysis unit. Every month, the same three blood tests are ordered for every patient, in addition to other patient-specific tests. What is an efficient way to facilitate this recurring situation by leveraging your system capabilities?

Include an exploding charge in the chargemaster to order all three tests with one entry.

In the HHPPS, what does the abbreviation LUPA stand for?

Low-utilization payment adjustment

In Medicare's prospective payment system for skilled nursing facilities, which data set determines a resident's classification into a resource utilization group?

MDS

In Medicare's prospective payment system for long-term care hospitals, what classification is used to adjust for case mix?

MS-LTC-DRGs

All of the following elements are part of the IRF PPS except:

Major diagnostic category

What tool does the SNF PPS use to annually adjust the base rate for differences in local markets?

Market Basket Index

What is the administrative data element that distinguishes one patient from another?

Medical record number

All of the following items are packaged under the Medicare Hospital Outpatient Prospective Payment System (OPPS), except:

Medical visits

What is the term for an MCO that serves Medicare beneficiaries?

Medicare Advantage

Which of the following is not used to reconcile accounts in the patient accounting department?

Medicare Code Editor

Which Medicare contractor reimburses acute care hospitals on behalf of Medicare?

Medicare administrative contractor (MAC)

Which type of healthcare insurance policy provides benefits to pay for Medicare deductibles and coinsurance?

Medigap

The MS-DRG payment includes reimbursement for all of the following inpatient services except:

Physician hospital visit

What is the term for the contract between the healthcare insurance company and the individual or group for whom the company is assuming the risk?

Policy

All of the following types of diagnoses are used in the IRF PPS except:

Principal

In which type of reimbursement methodology do healthcare insurance companies determine payment to providers before the services have been delivered?

Prospective payment

What term is used to indicate that an ambulance service entity is associated with a medical facility?

Provider

Who assumes the risk of loss in caring for a patient who is covered under a capitation contract?

Provider

Which of the following is not a function of the Indian Health Service (IHS)?

Provides only inpatient healthcare services

What is the purpose of a random audit of coded data? Select all that apply.

Quality monitoring

Recovery Audit Contractors are different from other improper payment review contractors because:

RACs are reimbursed on a contingency-based system

Which discounted fee-for-service healthcare payment method does Medicare use to reimburse physicians?

RBRVS

Under Medicare's prospective payment system for skilled nursing facilities, which healthcare service is excluded from the consolidated payment?

Radiation therapy

In the United States, what is healthcare insurance?

Reduction of a person's or a group's exposure to risk for unknown healthcare costs by the assumption of that risk by an entity

All of the following actions reflect the roles of PCPs in MCOs EXCEPT:

Refer patients to colleagues for immunizations and other general care

In the healthcare industry, what is the term for receiving compensation for healthcare services that were previously provided?

Reimbursement

Which APC component is a measure of the resource intensity of a particular procedure or service?

Relative weight

A patient, who was a Medicaid recipient, asked about the types of financial incentives that the MCO used. What should the MCO's administrator do?

Release summaries of the financial incentives

In which type of reimbursement methodology does the health insurance company have the greatest degree of risk?

Retrospective

A payer has advised your hospital that it is auditing records from 2010 due to a suspected payment error. Your hospital's first action should be to _____.

Review the contract to determine whether this is a violation of the look-back period clause.

In the healthcare industry all of the following benefits terms mean the amount during a timeframe beyond which all covered healthcare services for an insured or dependent are paid 100 percent by the insurance plan except:

Rider

What is the optimum chart completion window for revenue cycle purposes?

Within the bill hold period

For what type of care should the physician practice manager expect to work with a case manager?

Workers' compensation

Which of the following is an example of fraud?

Billing for a service not furnished as represented on the claim

In MS-DRGs, for what is the case-mix index a proxy?

Consumption of resources

The coverage requirements for Medicare beneficiaries' hospice services include all the following stipulations except:

Beneficiary must die within six months of entering hospice

Use the information in figure/image to answer the following question. The worker-subscriber had had bronchitis for the past eight days. Feeling miserable, she went to the local hospital's Emergency Department for care. She received a prescription for antibiotics. What co-payment should the hospital collect?

$50

Which is the correct formula for wage index adjusting a payment?

(payment rate * labor portion * WI) + (payment rate * non-labor portion)

Office Visit $10 Specialist Copay $10 Emergency $50 Plan Codes 621/121 Use the information above to answer the following question: The worker-subscriber went to her general physician. The purpose of her visit was follow-up for her hypertension that she has had for the past five years. What copayment should the physician's office collect?

10

All of the following dimensions are used to calculate an HHRG except:

25 days

An ambulance responds to a 911 call and arrives at a multi-car automobile accident. The ambulance takes three Medicare beneficiaries to the closest hospital. Under the Multiple-Patient transport provision how much will the ambulance service receive for each beneficiary?

60%

Under the ASC PPS Medicare payment equals ____ percent and the beneficiary copayment equals ____ of the total reimbursement for services provided.

80 / 20

The policies and procedures section of a Coding Compliance Plan should include:

: Correct All of the above Answers: Upcoding Coding medical records without complete documentation Correct use of encoding software Correct All of the above

Describe at least three sources of errors that cause claim denials.

Answers will vary; possible sources include outdated CDM codes used on claims; data entry errors; inexperienced HIM coders; incorrect group healthcare numbers or Medicare healthcare identification claim numbers for patients; and incomplete data in required fields of the electronic order entry systems or on paper forms

All of the following functions are ways that MCOs work toward their goal of quality patient care EXCEPT:

Applying PMPM payment system

All of the following are cost-sharing provisions except:

Benefit

What healthcare organization is one of the most influential in the healthcare sector because it insures nearly one in three Americans?

BCBSA

In the IPPS, what is the term for each hospital's unique standardized amount based on its costs per Medicare discharge?

Base payment rate

There are several physicians on staff who continue to write "urosepsis" in the patient charts. The term "urosepsis" has no meaning in the ICD-10-CM code set. Coders repeatedly have to query the physicians to ask for a definitive diagnosis. What is the most efficient way to solve the problem?

CDI staff should be alert to this documentation issue so they query the term while the patient is still in house, and the physicians should be counseled by the chief medical officer or CDI liaison regarding the correct documentation.

Which of the following coding systems was created for reporting procedures and services performed by physicians in clinical practice?

CPT

Which type of reimbursement methodology is associated with the abbreviation "PMPM"?

Capitated payment

In the healthcare industry, what is another term for "fee"?

Charge

All of the following data elements are on a remittance advice except:

Claim attachment

What is an example of a charge that usually would be reviewed by an HIM coder?

Claim is failing due to potentially incomplete code, including missing modifiers.

In a typical acute-care setting, which revenue cycle area uses an internal auditing system (scrubber) to ensure that error free claims (clean claims) are submitted to third-party payers?

Claims processing

Which type of healthcare insurance policy offers the widest ranging coverage but requires the insured to pay coinsurance until the maximum out-of-pocket costs are met?

Comprehensive

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is available for:

Correct B and C Answers: Veterans of the armed forces Spouse or widow(er) of a veteran meeting specific criteria Children of a veteran meeting specific criteria Any spouse, widow(er) or children of a veteran Correct B and C

In states where there is not a mandated fund for workers' compensation which of the following is an option for employers?

Correct B and C are correct Principles of Healthcare Reimbursement Instructor's Guide Chapter 2 Answers: Use the Federal program operated by the Office of Workers' Compensation Programs Purchase workers' compensation insurance from a private carrier Provide workers' compensation self-insurance coverage Do not offer workers' compensation to their employees A and B are correct Correct B and C are correct Principles of Healthcare Reimbursement Instructor's Guide Chapter 2

True or False? Hospice services are curative meaning that care providers seek to restore or maintain function

Correct False

True or False? Rural health clinics must be located in nonurbanized areas with health professional shortages.

Correct True

What are key issues that typically arise in a decentralized model? (Select all that apply.)

Coverage

In your facility, inpatients and same-day surgery patients are registered by the patient access department, but the ED and all of the ancillary departments have their own registrars who report to their business managers. What term describes the organization of patient access services in your hospital?

Decentralized

Which type of healthcare insurance policy provides benefits to a homeowner who requires an 8-month recuperation after a fall down her basement stairs?

Disability income protection insurance

Which IPPS provision is provided to facilities that experience a financial hardship because they provide treatment for patients who are unable to pay for the services?

Disproportionate share hospital

Which is an example of a practice that will most likely result in late charges?

Due to low volume, radiation oncology collects their charges and posts once a week.

Under the Ambulance Fee Schedule, the __________ is used to determine the level of service for ground transport.

EMS provider skill set used during the transport

Which of the following is not a facility-level adjustment under the IPF PPS?

Electroconvulsive therapy

Define the acronym EDI.

Electronic Data Interchange

Describe how charges for healthcare at all of the points of services are collected and reported to the appropriate patient account for entry onto the provider's claim.

Electronic order entry systems help to capture charges at their point of service delivery. If facilities lack electronic systems, staff collect paper-based charges on charge tickets, superbills, or encounter forms to be entered by billing staff into the patient accounting system.

All of the following phenomena are typical exclusions found in insurance plan riders except:

Emergency care under the prudent layperson standard

All of the following types of procedures and services typically require prior approval except:

Emergency services for suspected stroke

Which of the following entities is also known as a "group plan"?

Employer-based healthcare insurance plan

To which of the following factors is health insurance status most closely linked?

Employment

What is the best strategy for ensuring compliance with all rules and regulations regarding coding and reimbursement?

Establish a robust and comprehensive compliance program

In the healthcare industry, what is the term for the written report that insurers use to notify insureds about the extent of payments made on a claim?

Explanation of Benefits

Which of the following activities do MCOs use as financial incentives to control costs?

Incorrect A and B only Monitoring the settings of care Rewarding providers who meet targets with bonuses Varying members' rates of cost-sharing A and B only Correct All of the above

In which setting, does Medicare pay for the hospice benefit?

Incorrect A and B only Answers: Patients' homes Acute-care inpatient hospitals Skilled nursing facilities A and B only Correct All of the above

The medical record should be reviewed against the posted charges daily in order to ensure that nothing was missed.

Incorrect B & C Answers: Indirect medical education High cost outlier cases New medical services and new technology Correct A &B B & C

The potential benefit to providers of pay-for-performance (P4P) programs is _____.

Increased reimbursement

Who are "dual eligibles"?

Individuals who are eligible for Medicare and have Long-Term care insurance

The patient presented in the ED at 5 a.m. complaining of chest pain. Tests were done in the ED. The physician wrote an order to move the patient to observation status at 10 a.m. and the patient was transferred to telemetry. At 2 p.m. additional testing confirmed an acute myocardial infarction and the physician wrote an order to admit. The patient remained in telemetry, where he was treated until he expired at 11 p.m. that night. What is the patient's status at discharge?

Inpatient, because the order triggered inpatient status.

What term means a network of organizations that directly provides or arranges to provide a coordinated continuum of services to a defined population and takes accountability for the cost, quality, and outcomes of care?

Integrated delivery system

How many times can a claim be re-billed?

It depends on the payer contract or policies

Which of the following is not a separately payment service under the ASC PPS?

Laboratory services

All of the following are elements of prescription management EXCEPT:

Links to electronic banking

Which of the following is a facility-level adjustment in the ESRD PPS?

Low volume facility

Claim edits help to identify errors that will cause a claim to be rejected if not addressed. An example of an error that can be identified is _____.

Mutually exclusive CPT/HCPCS codes and medically unlikely quantities

Which national model for the delivery of healthcare services is financed by general revenue funds from taxes?

National health service (Beveridge) model

In Medicare's prospective payment system for federally qualified health centers, which factor is a risk adjustment?

New patient status

When a patient is pronounced dead prior to an ambulance being called, which of the following payment provisions is followed under the Ambulance Fee Schedule?

No payment is made to the ambulance supplier/provider.

Which of the following entities does not perform improper payment reviews for CMS?

None of the above QIO CERT RACs MACs

A patient is calling you to complain. She has just learned from a friend that your hospital does a lot of medical research and she claims she wasn't told about that in advance. What should the patient have signed at registration that would have alerted her to this use of her data?

Notice of Health Information Practices

What is the rate year (RY) for IPPS?

October - September

A patient is scheduled for elective services and pre-registration has determined that insurance doesn't cover all of the reimbursement for the procedure. What does the registrar do first?

Offer financial counseling services

How many comorbid conditions can be included in the comorbidity adjustment in the ESRD PPS?

One

What are two sources of new charge description master codes?

One source of new codes is the CMS release of updates to codes and billing guidance; the other is performance of new services at the healthcare provider that require line items to be added to the system.

What tool does CMS require that home health agencies use to collect and to report clinical data on patients?

Outcome Assessment and Information Set (OASIS)

Facilities expect what percentage of their claims to be clean on the first try?

Over 90%

Which type of MCO allows patients to choose how they will receive services at the time that the patients need the service?

POS

Which type of service includes an APC per diem rate that includes payment for all services provided in a single day of service under OPPS?

Partial Hospitalization

There are 3 parties in healthcare reimbursement. Who is the first party?

Patient or guarantor

There are 3 parties in healthcare reimbursement. Who is the third party?

Payer

Which of the following concepts is a guiding principle for prospective payment?

Payment rates are established in advance of the healthcare delivery and are fixed for the fiscal period to which they apply.

Which of the following phrases mean "per head"?

Per capita

In the healthcare sector, what is the term for a group of individual entities, such as individual persons, employers, or associations, whose healthcare costs are combined for evaluating financial history and estimating future costs?

Risk pool

Under the hospice payment system, which category of daily rate is the LOWEST?

Routine home care

What is the term for healthcare providers that, by mandate or mission, organize and deliver a significant level of healthcare and other health-related services to uninsured, underinsured, low-income, Medicaid, and other vulnerable populations or patients?

Safety-net provider

All of the following methods are types of episode-of-care reimbursement except:

Self-insured plan

Which type of RAC review combines data analysis and submission of medical records to the RAC?

Semi-automated

All of the following are true of state Medicaid programs except:

Services offered to beneficiaries are the same in each state.

All of following types of organizations represent ways of integrating health organizations EXCEPT:

Solo physician practice

In which type of HMO are the physicians employees?

Staff model

What converts the MS-LTC-DRG into an unadjusted payment amount?

Standard federal rate

True or False? Disease management is closely associated with coordination of care tools of MCOs because efforts of multiple providers must be synchronized in disease management.

True

The physician marked his superbill for a moderate level of care for every patient, based on the concept that historically, on average, his reimbursements for all patients have been at that level. Additionally, he considered that he would save time, both for himself and his biller, by not having to figure out the actual time spent and level of complexity of medical decision-making required to assign the actual CPT E/M level for the case. His biller is curious and asks you whether this is appropriate. Your response is _____.

Systematic, intentional miscoding of cases is fraud and he should not do this.

Which government-sponsored program provides coverage for the dependents of active members of the armed forces (ADFM).

TRICARE

You have reviewed the OIG work plan for the coming year and note several coding issues that you want to make sure are accurately addressed by your coders. What is your first plan of action?

Targeted review

Which piece of legislation called for the first hospital inpatient prospective payment system? This piece of legislation also allowed some hospital setting to retain their cost-based payment systems.

Tax Equity and Fiscal Responsibility Act (TEFRA)

Which federal law authorized payment for the Medicare hospice benefit?

Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982

Which government-sponsored program is designed to help needy families achieve self-sufficiency?

Temporary Assistance for Needy Families program (TANF)

Where and when did health insurance become established in the United States?

Texas, 1929

Which of the following is not a standard that must be met to qualify as a Medicare-certified ASC?

The ASC may share a national identifier or supplier number under Medicare with another entity

Within the IPF PPS which of the following statements is true?

The cost for psychiatric cases decreases as the length of stay increases

In the APC system, an outlier payment is paid when which of the following occurs?

The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount.

A Medicare patient was discharged from one acute IPPS and admitted to another acute IPPS hospital on the same day. How will the two acute IPPS hospitals be reimbursed?

The first hospital receives a per-diem payment derived from the potential MS-DRG and the second hospital receives the full MS-DRG.

Describe the first step in the revenue cycle..

The first step in the revenue cycle is preclaims submission activities such as collecting responsible parties' information, educating patients about their ultimate financial responsibility for services rendered, collecting appropriate waivers, and verifying data about procedures before they are performed and their charges submitted.

In the accounting system of the physician office, the account is categorized as "self-pay." How should the insurance analyst interpret this category?

The guarantor will pay the entire bill.

What is the impact of clean claims on cash flow?

The higher the percentage of clean claims, the faster cash is received to cover expenses

The ED accounts require a level charge and the hospital wants all service-specific goods, such as splints, casts, and IVs to be charged separately in order to track costs. The hospital does not want to invest in a new ED system to capture charges concurrently. Currently, a comprehensive charge ticket is created for every encounter and ED staff post the charges. Sometimes, these paper tickets get lost, misposted, or posted late. What internal control should be put in place to ensure that all appropriate charges are captured on a timely basis?

The medical record should be reviewed against the posted charges daily in order to ensure that nothing was missed.

Under the ASC List multiple procedures performed during the same surgical session are reimbursed at which of the following rate?

The procedure in the highest APC receives full payment and the remaining procedures receive half (50 percent) payment.

Why do duplicate medical records have to be merged?

This can cause patient care problems and billing errors

Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to calculate the group's premiums?

To assure that the pool is large enough to pay losses of the entire group

Why did Congress pass the Health Maintenance Organization Act of 1973?

To encourage the delivery of affordable, quality healthcare

Both parents of a dependent child had employer-based group health insurance. Per the "birthday rule," the primary payer for the dependent child is the insurance of the parent whose birthday comes first in the calendar year.

True

True or False? DME is EXCLUDED from the HHPPS.

True

True or False? Episode-of-care management includes capitated reimbursement and global payment.

True

True or False? Even though Medicare-severity long-term care diagnosis related groups (MS-LTC-DRGs) are based on the same general factors as the acute-care MS-DRGs for the IPPS, MS-LTC-DRGs differ from acute-care MS-DRGs because MS-LTC-DRGs have different relative weights and use quintiles for low volumes.

True

True or False? HIPPS codes are called "intelligent" because the number or letter in each position provides information.

True

True or False? In private or commercial healthcare insurance plans, covered conditions are patient conditions, diseases, or injuries for which the healthcare plan will pay and, correspondingly, covered services are services related to treating the covered conditions, diseases, or injuries.

True

True or False? In the healthcare sector, when a patient's healthcare services are covered under a voluntary healthcare insurance plan, the person who pays the remainder of a healthcare bill, after the healthcare insurance company has paid, is called the guarantor.

True

True or False? Payers that use per-diem payment rates reimburse the provider a fixed rate for each day a covered member is hospitalized

True

True or False? Providers' reimbursement is faster and more accurate when they submit clean claims to third-party payers than when they submit dirty claims.

True

True or False? The constant trend of increased national spending on healthcare is a concern because as spending on healthcare increases, the money available for other sectors of the economy decreases.

True

True or False? Under Medicare's hospice services payment system, patients may vary among the four categories of daily rates.

True

What is the maximum number of APCs that may be assigned per encounter?

Unlimited

Which of the following in not an adjustment provided under the Ambulance Fee Schedule?

Urban area service adjustment

In the healthcare insurance sector, what does UCR stand for?

Usual Customary and Reasonable

A patient with which condition is an appropriate candidate for an LTCH?

Ventilator-dependent emphysema

All of the following services are typically reviewed for medical necessity and utilization EXCEPT:

Well-baby check