Midterm - 1265

Tatiana, who is a Medicare patient, is seen in at Smiling Faces Physician Practice. The total charge for the office visit is $125.00. Tatiana has previously paid her Medicare Part B deductible. The Medicare physician fee schedule amount for this service is $84.00. The nonparticipating Medicare fee schedule amount for this service is $79.80. Tatiana's provider was a physician assistant that performed the service incident to Dr. Lee, who is a Medicare participating physician. What is the total amount that CMS will reimburse for this encounter?

$84.00

Identify the correct order of steps for SNF payment determination.

1. Choose urban or rural base rate 2. Adjust for geographic factors 3. Adjust for case mix 4. Adjust for day of stay 5. Sum the components

Felix is a Medicare Resident in a SNF. He is recovering from a hip replacement and has a function score of 7. What is PT case-mix index used in the per diem reimbursement calculation?

1.70

Skilled nursing facility services are covered under Medicare Part A. Under this benefit Medicare beneficiaires are eligible for up to ____ days of SNF-covered services per benefit period?

100

In the CMS ACO model, what is attribution?

A beneficiary is assigned to a particular ACO.

Medicaid

A federal and state assistance program that pays for health care services for people who cannot afford them. Added to Social Security in 1965.

Medicare

A federal program of health insurance for persons 65 years of age and older. Established in 1965. Implemented 1966

prospective reimbursement

A method of payment in which certain preestablished criteria are used to determine in advance the amount of reimbursement. Includes Capitation, Case-Rate Methodology, Global, payment method, and bundled payment methodology

Which of the following statements is true about APCs?

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

All of the following activities are steps in medical necessity and utilization review except:

Administrative review

For which clinician is Medicare's resource-based relative value scale resource assignment system modified by a formula that includes base units and time?

Anesthesiologists

All of the following activities are service management tools used in controlling costs except:

Applying an episode-of-care payment system

Insurance policies include procedures for determination of other party liability (OPL). When a(n) _________ is involved, the insurance company will need to perform a determination of other party liability.

Automobile insurance

Use the following excerpt from table 7.1, Payment status indicators for 2020, to answer the following question. J1 Comprehensive APC payment All services are packaged with the primary J1 service except services with SI F, G, H, L, and U; ambulance services; diagnostic and screening mammography; rehabilitation therapy services; self-administered drugs; all preventive services; and certain Part B inpatient services Which of the following services is not packaged with a J1 procedure or service?

Brachytherapy source—U

The methodology used for critical care services, imaging, and mental health services that results in composite APCs is ______________.

Bundling

What is the target population of the Children's Health Insurance Program (CHIP) (Title XXI)?

CHIP targets uninsured children whose family income level is too high to qualify for Medicaid but is insufficient to pay for private health insurance.

CMS uses this reimbursement methodology when they contract with Medicare Advantage Payers to care for Medicare beneficiaries under Medicare Part C.

Capitation

Describe at least three ways in which MCOs work toward their goals of quality patient care?

Careful selections of providers, use of care tools, maintenance of accreditation

Dayna is analyst at Community Hospital. She is examining inpatient cases for the payer Super Payer. She notices that all pneumonia cases have the reimbursement amount of $4,000 and that all CHF cases have a reimbursement rate of $4,200. The reimbursement is consistent for the entire year. Which reimbursement methodology is Super Payer using to reimbursement Community Hospital for inpatient admissions?

Case-rate methodology

Describe how payment status indicators represent reimbursement methodologies

Code that establishes how a service, procedure or item is paid in O P P S •Fee schedule •A P C •Reasonable cost •Not paid

Private health insurance model

Collect premiums to create a pool of money. Pool of money is used to pay claims. Workers and employees contribute to the pool. Insurance company determines the contribution. Adapted by the U.S. and Switzerland.

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

Consumption of resources

Wes is enrolled in Medicare Part A. He had his first hospital encounter this March. He was admitted for congestive heart failure and stayed three days? Which of the following will Wes need to pay?

Deductible and copayment amount

Explain the patient-driven payment model

Designed to assign residents to payment categories based on individual patient characteristics rather than reimbursing facilities based on therapy minutes

Jameson is calculating the MS-DRG for an inpatient admission. He is determining if the encounter is medical or surgical. Which of the following should he do?

Determine if any procedure coded is designated as an OR procedure in the MS-DRG Definitions Manual.

Describe the OPPS provisions

Discounting, Interrupted Services, High-cost outlier, rural hospital adjustment, cancer hospital adjustment, pass-throughs

Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was canceled after the patient was diagnosed with mononucleosis. On today's visit, the patient is started on prednisone for severe sore throat and difficulty swallowing. The patient was accompanied by his parents who have health insurance through the mother's employment at the State Department of Treasury. Who is the second party in this healthcare reimbursement scenario?

Dr. Gilbert

universal health coverage

Ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

national health service model

Entire system owned and operated by government

Medicaid is a joint program between _________and _________governments?

Federal and state

Dr. McGee is a primary care physician. Several of Dr. McGee's patients are insured by Super Payer. Super Payer reimburses Dr. McGee for each service she provides during a clinic visit. Which reimbursement methodology does Super Payer use to reimburse Dr. McGee?

Fee Schedule

CMS created Comprehensive APCs with the goal of moving toward a _______ packaged outpatient PPS.

Fully

Comprehensive APCs (C-APCs) have status indicators J1 and J2. They are CMS' first step in moving OPPS from a partially packaged system to a _____ packaged system.

Fully

Dr. Jones is a podiatrist who performs over 100 bunionectomies a year. Several of Dr. Jones' patients are insured by Super Payer. Super Payer reimburses Dr. Jones one amount for the preoperative visit, the surgery, and routine post-operative follow-up visits. Which reimbursement methodology does Super Payer use to reimburse Dr. Jones?

Global payment method

Employer based health insurance

Group plans for groups of employees. Typically have lower premiums, deductibles, and cost sharing, and greater benefits than individual healthcare plans

Explain the cost controls used in managed care

Health Maintenance Organizations - health entities that combine that combine the provision of health insurance and the delivery of healthcare services using the principles of managed care

Describe the healthcare spending trend in the US over the past decade.

Healthcare spending dollar amounts continue to increase, but at a lesser rate that previously experienced.

What is the purpose of the cancer hospital adjustment provision?

Help hospitals that have would have a higher payment to cost ratio compared to an average facility

Describe the Medicare hospital acute inpatient payment system provisions

High-cost outlier cases, new medical services and technologies, transfer cases, post-acute care transfer policy

List at least three services that must be included in CHIP plans and benchmark-equivalent plans?

Impatient hospital services, outpatient hospital services, laboratory and radiology services

What is the main differentiating factor of an Advanced Alternative Payment Model (APM)?

Include significant risk for providers and offer a potential for significant rewards

Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was canceled after the patient was diagnosed with mononucleosis. On today's visit, the patient is started on prednisone for severe sore throat and difficulty swallowing. The patient was accompanied by his parents who have health insurance through the mother's employment at the State Department of Treasury. Who is the third party in this healthcare reimbursement scenario?

Insurance Company

Why does the NTA variable day adjustment impact the first three days of the resident's admission?

It impacts the first three days because extensive services and resident comorbid conditions are evaluated during those days.

Describe severity of illness levels of MS-DRGs

MCC - Major or extensive, CC - Moderate, Non/CC/MCC - Minor

Which of the following is not a limitation typically included in a health insurance policy?

Maximum out of pocket provision

Which of the following statements about the New Medical Services and New Technologies provision is false?

Medicare encourages facilities to forgo using new services and technologies for Medicare beneficiaries because they are too expensive.

Which of the following is not a principle of revenue integrity?

No oversight

Which of the following PDPM components of care is not adjusted by characteristics of the resident?

Non-case-mix

Which of the following does not impact the CMG used in the SNF Services Payment System?

Number of therapy hours per week

Which reimbursement methodologies are used in OPPS?

OPPS - Fee schedule payment, prospective payment (case-rate) , and reasonable cost payment

The variable day adjustment policy is applied to which PDPM components?

PT/OT and NTA

Reimbursement for minor ancillary services associated with a significant procedure are combined into a single payment for the procedure. This is the definition of _________.

Packaging

An employee paying for 40 percent of the insurance premium through payroll processing is an example of a transaction between ________ and ________.

Patient; employer

Payer A 62% billed charges 56% of billed charges Payer B $6,500 obstetric delivery case rate Fee Schedule $70 per clinic visit $85 per initial OT evaluation $50 per OT visit (non-eval) Payer C $2,100 obstetric delivery per diem $75 per clinic visit $45 per OT visit Payer D $6,350 obstetric delivery case rate $65 per clinic visit $55 per initial OT evaluation $35 per OT visit (non-eval) Patient 72341 is admitted as an inpatient for delivery. The length of stay is three days. The charges for the encounter are $10,425.00. The cost of the encounter is $5,848.45. Which payer will reimburse the hospital the highest amount?

Payer B

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 reimbursement methodology is used in the SNF services payment system?

Per Diem Rate

Which of the following reimbursement methodologies is not utilized in the Outpatient Hospital Services Payment System?

Percent of billed charges

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

Physician hospital visit

What is a benefit of a multidisciplinary approach to RCM?

Possible answers: Promotes collaboration, Emphasis on education, Proactive stances on issues

Illustrate MS-DRG assignment

Pre-MDC, MDC Assignment, Surgical or Medical, Refinement

Describe the types of managed care organizations

Preferred provider organizations, Point-of-service

What is the term for the set fee that a policyholder or certificate holder must periodically pay a health insurance plan in return for healthcare coverage?

Premium

individual healthcare insurance

Private healthcare insurance policy, purchased by individuals and families who do not have access to group health coverage.

Which of the following activities are utilized as financial incentives by MCOs?

Productivity (number of visits per day)

A physician office submitting an invoice (claim) for payment when the patient has health insurance is an example of a transaction between ________ and ________.

Provider; third-party payer

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

Purchase workers' compensation insurance from a private carrier

Three main components of revenue cycle

Reduced cost to collect, performance consistency, coordinated strategic goals

In the US, what is health 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

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

Relative Weight

· Differentiate retrospective reimbursement methodologies from prospective reimbursement methodologies

Retrospective - few incentives to control cost, little incentive to order less expensive services, rewards providers for more services regardless of whether such services are warranted Prospective - Creates incentives to substitute less expensive procedures and tests, creates incentives to delay procedures and treatments, premature discharge in the inpatient setting

What are the goals of revenue integrity?

Revenue integrity is performing revenue cycle duties to obtain operational efficiency, compliance adherence, and legitimate reimbursement. The goal of this approach is to produce a claim that is clean, complete, and compliant.

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

Services offered to beneficiaries are the same in each state.

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

Spouse, widow(er), or children of a veteran meeting specific criteria

A worker had group health insurance coverage through her employer. The worker's household included her spouse, two natural children (ages 28 and 12), an adopted child (age 8), and the worker's mother (age 58). Who may be included under dependent coverage in the health insurance policy?

Spouse; natural child, age 12; and adopted child, age 8

Macy is a Medicare Resident in a SNF. Macy has lung cancer and has a function score of 13. What is the OT case-mix group used in the per diem reimbursement calculation?

TK

Which government-sponsored program provides coverage for active-duty service members of the armed forces (ADSM)?

TRICARE

Which TRICARE program is the most economical program for military families, and why is it less expensive than other options?

TRICARE Prime or TRICARE Prime Remote is the least-expensive program for active duty family members because this managed care program has no enrollment, deductible, or copayment fees.

Describe the skilled nursing facility value-based purchasing program

The SNF VBP ties facility performance for established quality measures into the SNF services payment system

Define deductible.

The deductible is the annual amount of money that the policyholder must pay before the health insurance plan will assume liability for the remaining charges or covered expenses.

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.

One of the two domains in the HAC reduction program tracks healthcare associated infections (HAI). Name two measures used in this domain.

The following measures are used in the HAI domain: central line-associated bloodstream infection, catheter-associated urinary tract infection, surgical site infection for colon and hysterectomy, Methicillin-resistant Staphylococcus aureus bacteremia, and Clostridium difficile infection.

What are the four domains used in the Hospital Value-Based Purchasing Program?

The four domains include (1) clinical outcomes, (2) person and community engagement, (3) safety, and (4) efficiency and cost reduction.

Dr. O'Neil's physician practice has a PMPM contract with super Payer to provide primary care services. Super Payer uses a risk adjustment model to determine the PMPM amounts. The beneficiary risk score breakouts are provided below: Number of Beneficiary Risk Score Level PMPM Amount 100 1 - 1.00 risk score $200.00 135 2 - 1.25 risk score $250.00 150 3 - 1.50 risk score $300.00 125 4 - 1.75 risk score $350.00 90 5 - 2.00 risk score $400.00 How much reimbursement will Dr. O'Neil's physician practice receive each month from Super Payer to provide primary care for the 600 beneficiaries?

The monthly reimbursement total is $178,500. The calculation is (100 × $200) + (135 × $250) + (150 × $300) + (125 × 350) + (90 × 400).

Which of the following statements about the IPPS high-cost outlier provision is false?

The outlier payment ensures that hospitals will not experience a financial loss for the encounter

Explain why the principal diagnosis is important under MS-DRG grouping logic.

The principal diagnosis is important because it establishes the MDC for the admission. Every diagnosis is assigned to an MDC in the MS-DRG Definitions Manual.

Name the three steps in utilization review.

The three steps of utilization review include clinical review, peer clinical review, and appeals consideration.

Super Payer has a contract with Community Hospital to provide inpatient care for their beneficiaries. They have agreed to a per diem reimbursement methodology. ICU days are reimbursed at $5,000 per day and medical bed days are reimbursed at $3,500 per day. Community Hospital submitted a claim for a six-day LOS. Two of the six days were ICU days and four of the six days were medical bed days. What is the total reimbursement owed to Community Hospital for this admission?

The total reimbursement is $24,000. The calculation is (2 × $5,000) + (4 × $3,500).

Calvin saw his PCP, Dr. Washington because he had a fever and a sore throat. Dr. Washington ordered and performed a rapid strep test. Calvin's test was positive, and he was diagnosed with streptococcal pharyngitis (strep throat). Dr. Washington wrote Calvin a prescription for amoxicillin to treat pharyngitis. Dr. Washington submitted the following charges to Calvin's insurance company, Super Payer: Clinic visit, level 2: $145 Rapid strep test: $50 Dr. Washington's practice has a contract with Super Payer and the reimbursement methodology is a fee schedule. The fee schedule rate for a level 2 clinic visit is $70 and the fee schedule rate for a rapid strep test is $10. What is the total reimbursement Dr. Washington will receive for Calvin's office visit?

The total reimbursement is $80. The calculation is $70 + $10. The reimbursement rate is not based on the provider's charges, so they are not used in the calculation.

Which of the following statements about SNF per diem payment is false?

There is only one per diem rate per resident stay.

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

True or False: The nine SI reimbursement methods currently used in the OPPS are: APC payment, per diem APC payment, comprehensive APC (C-APC) payment, conditional APC payment, composite APC payment, package payment, fee schedule payment, reasonable cost payment, and services not reimbursed under OPPS.

True

Giant ACO has agreed to a shared savings rate of 65 percent and a shared loss rate of 40 percent with CMS. Giant ACO participates in a __________ risk agreement.

Two-sided

Retrospective Reimbursement

Type of reimbursement in which the payer bases payment on the actual resources expended to deliver the service(s). Includes Fee schedule, Percent of billed charges, and Per Diem Payment

Illustrate the variable per diem adjustment included in the payment model

Used six components - Nursing, PT, OT, SLP, NTA, and non-case-mix

Describe the structure of the Medicare hospital acute inpatient payment system

Uses Medicare severity diagnosis-related group (MS-DRG)

single-payer system

health care system in which the government collects all health care fees via taxes and pays out all health care costs

Revenue integrity

performing revenue cycle duties to obtain operational efficiency, compliance adherence, and legitimate reimbursement

There are three government-sponsored healthcare programs related to military service: TRICARE, VHA, and CHAMPVA. Who uses which program

veterans who are no longer serving in the military but were not dishonoraby discharged. A. VHA eligible family members of veteran who ispermanently or totally disabled due to their service or who died due to a military-related service or disability. B. CHAMPVA active duty servicemen and women and their families. C. TRICARE

Articulate Medicare value-based purchasing programs related to the hospital acute inpatient setting

•C M S: to optimize health outcomes by improving clinical quality and transforming the health system 1.Better care for individuals 2.Better health for the population 3.Lower costs through improvements

Illustrate how diagnosis coding is used in risk adjustment models

•I C D-10-C M diagnosis codes are used to determine the patient's health status. •Uses demographic characteristics and health status to predict future healthcare expenditures