Reimbursement Methodologies

What reports drove the establishment of value-based purchasing and pay-for-performance and systems in the healthcare sector?

- Crossing the Quality Chasm - Rewarding Provider Performance: Aligning Incentives in Medicare

Which of the following are major advantages of private group medical practices for physicians? Check all that apply!

-Cost sharing -Coverage sharing -Attending academic meetings -Informal consultations

Government spending has accounted for an increasing proportion of the health care dollar since...

1960

When did pay-for-performance systems first emerge in the healthcare sector?

1970s

What is the payment reduction for hospital and facilities that fail to successfully meet the requirements of Medicare's Pay for Reporting programs?

2% reduction

In most situations, for a facility to be defined as an LTCH, the lengths of stay of its Medicare patients must be at least how long?

25 days

In Medicare's prospective payment system for home health services, under the LUPA provision, what is the maximum number of visits for which an agency may receive reimbursement?

4

The Recovery Audit Contractor (RAC) appeals process has ____ levels.

5

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?

A and B - Inpatient deductible for the 90-day benefit period - Daily coinsurance payment for days 61 through 90

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?

A and B - Rehabilitation Plus Extensive - Rehabilitation

In the Hospital Value Based Purchasing program a facility's total performance score (TPS) is used to determine the amount of holdback dollars the facility has earned back. In regard to the TPS which is better?

A higher TPS is better

Which of the following is the correct format for Healthcare Common Procedure Coding System (HCPCS) Level II codes?

A1234

Much of the controversy surrounding health care delivery reorganizations, such as MC, concerns profit-making and its compatibility with the provision of quality, efficient, and _________ health care.

Accessible

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

In a typical acute-care setting, Aging of Accounts reports are monitored in which revenue cycle area?

Accounts receivable

In healthcare settings, the record of the cash the facility will receive for the services it has provided is known as which of the following terms?

Accounts receivable

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

Administrative review

Within a 60-day episode of care, what home health care services are consolidated into a single payment to home health agencies?

All of the above - All therapy (speech, physical and occupational) - Skilled nursing visits - Medical social services

Scrubbers are used by hospitals to identify which of the following errors that can cause claims rejections or denials?

All of the above - Incompatible dates of service - Nonspecific or inaccurate diagnosis and procedure codes - Lack of medical necessity

What targets should be the focus of pay-for-performance and value-based purchasing systems?

All of the above - Most significant problems in terms of quality or cost - Proportion of population covered by the service or provider - Availability of valid and reliable performance measures

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

All of the above - 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

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

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

Which of the following payment methods are global?

All of the above -Block grants - Surgical packages - Bundling

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

All of the above -Primary care provider - Gatekeeper - Primary care physician

For what reasons do MCOs survey their members for feedback?

All of the above -To determine their satisfaction with services - To obtain their perceptions of the plan's strengths and weaknesses and their suggestions for improvements -To learn their intentions regarding reenrolling in the plan

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

All parts of Medicare include a cost-sharing provision

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

All the above -Monitoring the settings of care -Rewarding providers who meet targets with bonuses -Varying members' rates of cost sharing

Which of the following types of care represent healthcare services delivered by MCOs?

All the above -Preventive -Wellness oriented -Chronic

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 activities are service management tools used in controlling costs EXCEPT:

Applying an episode of care payment system

In value-based purchasing and pay-for-performance systems, what is the term for the process of identifying the clinician who provided the care, is responsible for the care's quality, and is accountable for the care's cost?

Attribution

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

BCBS

Payments to physicians began to decline in the early 2000s as a result of the federal....

Balanced Budget Act (BBA)

Which of the following statements about the Veterans Health Administration is false?

Basic eligibility includes all veterans who served in active military service regardless of the separation condition

All of the following are cost-sharing provisions except:

Benefit

Which of the following is an example of fraud?

Billing for a service not furnished as represented on the claim

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

CMGs

Which type of compliance guidance is used by Medicare to communicate policies and procedures for the specific prospective payment systems' manuals?

CMS Program Transmittals

Combined Provider Organization

CPO

The term "soft coding" refers to:

CPT codes that are coded by the coders

Which of the following is not a function area of the revenue cycle?

Cafeteria

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

Capitated payment

__________ is a fixed prepayment per person to the health care provider for an agreed-on array of services.

Capitation

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

Charge

The bill that the pathologist's office submitted for a laboratory test was $54.00. In its payment notice (remittance advice), the healthcare plan lists its payment for the laboratory test as $28.00. What does the amount of $54.00 represent?

Charge

The dollar amount the facility actually bills for the services it provides is known as:

Charge

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

Claim attachment

In a typical acute-care setting, Charge Entry is located in which revenue cycle area?

Claims processing

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

In a typical acute-care setting, the Explanation of Benefits, Medicare Summary Notice, and Remittance Advice documents (provided by the payer) are monitored in which revenue cycle area?

Claims reconciliation/collections

Which of the following is not a use of the CDM?

Coder productivity

Cost sharing in which the policy or certificate holder pays a preestablished percentage of eligible expenses after the deductible has been met. The percentage may vary by type or site of service.

Coinsurance

When revenue cycle analysts examine MS-DRG relationships reporting they examine MS-DRG families for differences in _______ reporting.

Complication/comorbidity

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 difference between what is charged and what is paid is known as:

Contractual allowance

Which of the following is the definition of revenue cycle management?

Coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue

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

Copayment

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

Current Procedural Terminology (CPT)

Annual amount of money the policyholder must incur (and pay) before the health insurance will assume liability for the remaining charges or covered expenses.

Deductible

The increase in availability of point of service plans has continued in response to patient _______.

Demands

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

In IRFs, all of the following reasons are purposes for codes except:

Documenting patients' functional statuses

The amount of money owed a healthcare facility when claims are pending is called:

Dollars in accounts receivable

What is the name of the notice sent after the provider files a claim that details amounts billed by the provider, amounts approved by the payer, how much the payer paid, and what the patient must pay?

EOB

Exclusive Provider Organization

EPO

The common techniques MCOs use to control costs and quality are disease management, case management, wellness incentives, and patient ________.

Education

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

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

The remittance advice is provided to which party?

Facility

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? Out-of-pocket costs for subscribers and patients are decreasing.

False

True or False? Pay-for-performance and value-based purchasing systems are phenomena unique to the U.S. healthcare delivery system.

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

True or false? There are nationally recognized rules regarding the use of charge descriptions for CPT codes in the CDM.

False

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

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

Functional Independence Assessment Tool

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

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

Greater benefits for lower premiums

There are two major forms of PGP. The staff model and the...

Group model

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

HHRGs

Health Insurance Plan

HIP

Health Maintenance Organization

HMO

The trail from PGP to MC was blazed in part by the health services entities known as ___.

HMOs

In value-based purchasing and pay-for-performance systems, which incentive is financial?

Higher fee schedule

In Medicare's prospective payment system for home health services, what software is used to electronically submit data?

Home Assistance Validation and Entry (HAVEN)

All of the following elements are found in a charge description master, except:

ICD-10-CM code

Integrated Delivery System

IDS

Independent Practice Association

IPA

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

Who are "dual eligibles"?

Individuals who are eligible for Medicare and Medicaid

What tool, that drives payment, is used to collect information about Medicare patients in the IRF PPS?

Inpatient rehabilitation facility patient assessment instrument (IRF PAI)

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

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

International Clasification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

Which of the following is/are true of Children's Health Insurance Program (CHIP)?

It is a federal/state program and it varies from state to state (A and C are true)

Under Medicare's prospective payment systems for postacute care, which component is directly adjusted by the local wage index?

Labor portion

All of the following are elements of prescription management EXCEPT:

Links to electronic banking

What tool does CMS require that long-term care hospitals use to collect and to report clinical data on patients?

Long-term care hospital Continuity Assessment and Record Evaluation (CARE) data set

Which type of healthcare insurance policy provides benefits to a resident requiring nursing home care and services?

Long-term or extended care insurance

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

Low-utilization payment adjustment

Managed Care Organization

MCO

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

Medicare part C is a ___________ option known as Medicare Advantage.

Managed care

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

Market Basket Index

"Major tinkering"occurred in the 1960s when the federal government created the Medicare and _______ programs.

Medicaid

The first national social insurance program to finance medical care in the U.S. is called ________.

Medicare

Which entity is responsible for processing Part A claims and hospital-based Part B claims for institutional services on behalf of Medicare?

Medicare Administrative Contractor

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

Medicare Advantage

Which of the following compliance documents services as day-to-day operating instructions for administering CMS programs?

Medicare Claims Processing Manual

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

Medicare Code Editor

Which piece of legislation initiated the Reporting of Hospital Quality Data for Annual Payment Update (RHQDAPU) program?

Medicare Modernization Act

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

Medigap

What tool does CMS require that skilled nursing facilities use to collect and to report clinical data on residents?

Minimum Data Set (MDS)

Over time, virtually all group medical practices are of the ______________ variety.

Multispecialty

Which type of compliance guidance is used by Medicare to describe the circumstances under which specific medical supplies, services or procedures are covered nationwide by Medicare.

National Coverage Determinations

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

National health service (Beveridge) model

Which of the following entities does not perform improper payment reviews for Center for Medicare/Medicaid Services (CMS)?

None of the above (QIO, CERT, RACs, MACs)

For what variations in resource consumption does Medicare's prospective payment system for home health services account?

Number of therapy visits by a therapist

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)

Prepaid Group Practice

PGP

Point of Service

POS

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

POS

Preferred Provider Organization

PPO

What is the term for a model of primary care that seeks to meet the health care needs of patients and to improve patient and staff experiences, outcomes, safety, and system efficiency?

Patient-centered medical home

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

Patient/guarantor

Which component of Medicare's Value Based Purchasing plan monitors the action of reporting data in the proper format within the given timeframe?

Pay for Reporting

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

Payer

Which of the following phrases mean "per head"?

Per capita

Evidence-based clinical guidelines originate from all the following sources EXCEPT:

Physicians' personal clinical experiences

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

In a typical acute-care setting, Admitting is located in which revenue cycle area?

Pre-claims submission

In a typical acute-care setting, Patient Education of Payment Policies is located in which revenue cycle area?

Pre-claims submission

Which type of prescription drug is the LEAST costly for insureds using their drug benefit?

Preferred generic

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

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

Provider of care or services

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

Provides only inpatient healthcare services

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 and provide workers' compensation self insurance coverage (B and C are correct)

Under Medicare's prospective payment system for long-term care hospitals, all of the following elements are used to group patients into a MS-LTC-DRG except:

Qualifying diagnosis at acute inpatient hospital prior to admission to LTCH

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

RUGs

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

Radiation therapy

Coders in inpatient rehabilitation facilities (IRFs) use ICD codes for all the follow purposes except:

Reason for admission to the IRF

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

Recovery Audit Contractors (RACs) are reimbursed on a contingency-based system

Within the Medicare's VBP framework improving efficiency means

Reducing the cost to treat each beneficiary

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

_____________ is how hospitals describe payment received for services they have already provided.

Reimbursement

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 value-based purchasing and pay-for-performance systems, which attribute should adopted performance measures characterize?

Relevant

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

Resource Based Relative Value Scale (RBRVS)

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

Retrospective

Which of the following CDM data elements is nationally recognized?

Revenue code

What are the two major categories of pay-for-performance models?

Reward-based models and penalty-based models

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

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

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

Self-insured plan

Which type of Recovery Audit Contractor (RAC) review combines data analysis and submission of medical records to the Recover Audit Contractor (RAC)?

Semi-automated

Which of the following is not a benefit of an integrated revenue cycle?

Separation of physician practices

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

Services offered to beneficiaries are the same in each state.

Value-based purchasing and pay-for-performance and systems typically link all of the following components except:

Setting of care

Which is a characteristic of the "old" Revenue Cycle Management (RCM) approach?

Silo mentality

Which of Medicare's prospective payment systems for postacute care is a per diem?

Skilled nursing facility PPS

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

Solo Physician practice

In the healthcare sector, why are incremental implementations of value-based purchasing and pay-for-performance systems preferable to full-scale implementations?

Sponsors can evaluate policies and procedures

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

Spouse or widow(er) of a veteran meeting specific criteria and children of a veteran meeting specific criteria (B and C)

The worker had group healthcare insurance coverage through her employer. The worker's household included her spouse, two natural children (ages 28 and 12), an adopted child (age 8), a 6-month infant in the waiting period prior to adoption, and the worker's mother (age 58). Who may be included under dependent coverage in the healthcare insurance policy?

Spouse, natural child age 12, adopted child age 8, and 6-month infant in waiting period

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

During the 20th century, health care delivery grew from a cottage industry to a complex health care ___________.

System

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

TRICARE

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

Temporary Assistance or Needy Families program (TANF)

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

Texas, 1929

Most facilities begin counting days in accounts receivable at which of the following times?

The date the bill drops

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

The patient belongs to a managed care plan. The patient wants to make an appointment with an out-of-network specialist. The plan has approved the appointment as "out-of-network." What should the patient expect?

The patients out of pocket costs will be increased

Which of the following statements about the Hospital Readmission Reduction Program is false?

The program collects readmission data for only Medicare patients

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

What is the term that means making available to the public, in a reliable and understandable manner, information on a healthcare organization's quality, efficiency, and consumer experience with care, which includes price and quality data, so as to influence the behavior of patients, providers, payers, and others to achieve better outcomes?

Transparency

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

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? Facilities transmit IRF PAIs to the Centers for Medicare and Medicaid Services using CMS' free IRVEN software.

True

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

True

True or False? In 1910, early forerunners of health insurance plans appeared as "prepaid" group practices.

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 U.S. spends more on health care than any other country in the world, both on a gross basis and on a per capita basis?

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? In regard to accounts receivable management, the older the account or the longer the account remains unpaid, the less of a change that the facility will receive reimbursement for the encounter.

True

True or false? The Physician Feedback Program/Value-Based Payment Modifier program will include all physicians, regardless of practice size, by 2017.

True

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

Type of clinician providing services

What is the term that means evaluating, for a healthcare service, the appropriateness of its setting and its level of service?

Utilization review

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

Since the 2000s, what terms characterize the rate of establishing value-based purchasing and pay-for-performance and systems in the healthcare sector?

Wide-spread implementation

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

Workers Compensation

The physician nearly always has more medical knowledge, patients generally know more about their own ________.

history

How we pay for health care has both short-term and long-term ____________.

implications

Most people desire some sort of _________ to protect themselves against wild swings in health care costs.

insurance

The hourly payment method, common in service industries, is often referred to as time and __________.

materials

Ultimately, all costs of health care are borne by the ______.

people

It is third-party payers who have the best chance of __________ which providers will offer a good outcome.

predicting

About 62% of Americans have some type of ________ health insurance coverage.

private

A service is called ___________ when it can be marketed or sold as a commodity, which implies that a fixed price will buy a known quantity of that service.

productized

In the U.S., payers are generally categorized as private or...

public

Financing health care is a tension among the ethics and values we place on human life, the asymmetries of information, and uncertainty about care wrapped in nonmarketable ______.

risks

The fee-for-service method is common when the _______ of work is clear to both sides.

scope

Medicaid is supported by federal and state tax levy funds and is administered by the _____.

states

Anyone responsible for payment of a health care cost other than the patient or the provider is a...

third party payer

A considerable part of the constant upward trend in health care spending in the U.S. has been caused by factors other than simple ______________.

utilization