Final exam Health & Reimb

Clyde is enrolled in Medicare Parts A and B. He had a knee arthroscopy in January. This is Clyde's first health encounter for the year so he has not met his deductible. The approved amount for his surgeon is $550. How much does Clyde owe in cost sharing for the surgeon's services. Use the following excerpt from table 3.2, Part B Services 2020.

$308

List and describe the steps of MS-DRG Assignment.

1. Pre-MDC assignment-determine the original assessment 2. MDC Determination- see if it falls into a category 3. Medical/ Surgical Determination- review the medical case 4. Refinement - Improvement of the classification

Memorial Hospital's TOP 10 MS-DRGs The case-mix index for the top 10 MS-DRGs above is:

1.2846

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

CMS withholds of SNF PPS payments to fund the Nursing Facility VBP Program?

2 percent

Which individual MS-DRG has the highest reimbursement?

247

Sal is enrolled in Medicare Parts A and B. He goes to the hospital seniors clinic for congestive heart failure. He had a regular visit in November when Dr. Nauman examined him, checked his medications, and suggested a high fiber diet. The approved amount for her visit is $275. Sal met his outpatient deductible in February. What is his cost sharing amount for the visit to Dr. Nauman? Use the following excerpt from table 3.2, Part B Services 2020, for questions 5 and 6.

55

In the CMS-HCC model, beneficiaries with a risk score greater than 1 have ___________?

A higher expected cost of care than the average Medicare beneficiary

Under the OPPS, outpatient services that are similar both clinically and in use of resources are assigned to separate groups called ____.

APCs

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

The pathologist's office submitted a $54 bill for a laboratory test. In its payment notice (remittance advice), the healthcare plan lists its payment for the laboratory test as $28. What does the amount of $54 represent?

Billed charges

Compare the social insurance model and the private health insurance model. Discuss similarities and differences.

Both the social and private insurance models require employees and employers to contribute funds to a type of insurance company. In the social insurance model, the "insurance company" is called a sickness fund. They are heavily regulated by the government, including the determination of how much an individual must pay into the sickness fund. In the private health model, the insurance company follows some regulations established by the federal government. Still, in this model, the insurance company determines the individual's amount to obtain coverage. In both models, individuals may choose from which sickness fund or insurance company to obtain insurance coverage. Another main difference is that the social insurance model calls for universal healthcare coverage for a set of government-defined benefits. The private health model does not include universal coverage for all citizens.

Use the following excerpt from table 7.1, Payment status indicators for 2020, to answer the following question. 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

Describe how CMS incorporates severity of illness into the reimbursement for the Medicare Hospital Acute Inpatient Payment System.

CMS uses complication and comorbidity (CC) secondary diagnoses to assign severity of illness levels to MS-DRG families. There are three levels. Major complication and comorbidities (MCC) are conditions that have a major or extensive severity of illness level. Complication and comorbidities (CC) are conditions that have a moderate severity of illness level. Non (CC) conditions are those that have a minor severity of illness impact. Within an MS-DRG family, the admissions with MCCs are reimbursed the most, admissions with CC are reimbursed the next highest, and admissions with non CCs are reimbursed the least.

CMS uses the CMS-HCC model when contracting with Medicare Advantage payers. Why does CMS use this model to adjust capitation rates for their beneficiaries?

CMS uses the CMS-HCC model to provide fair and accurate payments for their beneficiaries. They also use the model to reward efficiency and high-quality care for Medicare's chronically ill population. If payment rates are not adjusted for those that are chronically ill and typically cost more to treat, payers may not expend the resources to provide care at the level required for high-quality standards.

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

Capitation

Dr. Ward is an endocrinologist who is part of the City Endocrinologist Specialists practice. Super Payer reimburses City Endocrinologist Specialists $450 per month for each of the 250 beneficiaries assigned to their care. Which type of reimbursement methodology is Super Payer using to reimburse City Endocrinologist Specialists?

Capitation

All of the following occurrences are considered "qualifying life events" except:

Car accident

For the five PDPM components that are adjusted for resident characteristics, the CMG assigned for the resident has an associated ______ that is a proxy for resource intensity.

Case-mix index

Define case-mix index.

Case-mix index is a single number that compares the overall complexity of the healthcare organization's mix of patients with the complexity of the average of all hospitals.

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

Case-rate methodology is widely used by government-sponsored insurance plans and commercial payers. Case-rate methodology incentivizes the provider (facility) to be more efficient and lower the cost for the case. Describe how case-rate methodology creates this incentive.

Case-rate methodology is a prospective payment system. The reimbursement rate is established in advance and does not change for the set period of time (i.e. contract period). If the facility wants to make a profit on an admission, the costs for the case must be less than the case-rate. If the costs are higher than the case-rate, the facility will lose money on the case. This creates an incentive to lower costs and provide the most efficient care possible so that the facility can earn a profit.

Which answer displays the correct order of steps for per diem payment determination?

Choose base rate; wage index adjust; adjust for case mix; adjust for day of stay; sum the components

D'Angelo is a denial specialist at Community Hospital. He is reviewing a denial where the payer claims there are insufficient clinical indicators in the health record to support the diagnosis of sepsis. What type of denial is D'Angelo reviewing?

Clinical validation

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

Consumption of resources

Describe why cost-sharing is a limitation in a health insurance policy.

Cost-sharing is a limitation because it limits the extent of the benefit. The benefit is limited because the beneficiary is required to bear some of the costs of the healthcare that they consume. The concept is designed to decrease the effect of moral hazard. For example, if a beneficiary has a $250 copayment associated with emergency department visits, the beneficiary may think twice about using the emergency department instead of urgent care for minor illnesses and injuries such as respiratory infections, sprained ankles, etc.

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

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.

Mr. Brown was admitted to the hospital with severe chest pains. During his encounter, he underwent a coronary artery bypass procedure (CABG) due to coronary artery disease (CAD). What is the first step in determining the MS-DRG assignment for this encounter?

Determine if the coronary artery bypass procedure is one of the pre-MDC procedures

Fatima is calculating the MS-DRG for an inpatient admission. She has determined that the encounter does not qualify for pre-MDC assignment. What is the next step in the MS-DRG assignment process?

Determine the MDC for the principal diagnosis.

Virginia is calculating the MS-DRG for an inpatient admission. Which of the following is not a valid refinement question for the MS-DRG set in the table above? Use the following table to answer question 6.

Did the patient have a coma?

Which of the following is a service that is excluded from Medicare Part A and Part B, but may be provided under Part C?

Eye exams including contacts and eyeglasses

Medicare has a SNF VBP program. This program withholds 2 percent of SNF PPS Payments to fund the program. The program determines a Total Performance Score (TPS) for each facility. How does the TPS impact facilities? What are the incentives and penalties?

Facilities ranked in the lowest 40 percent of all facilities will receive decreased reimbursements. Facilities with the highest ranking will receive incentive payments (payments greater than 100 percent). However, the program currently only returns 60 percent of the withholdings to the facilities with the highest TPS.

What is the basis of the "labor-related share?"

Facilities' costs related to payrolls, benefits, and professional fees

Which piece of legislation penalizes federal contractors who knowingly file false or fraudulent claims in order to defraud the US government?

False Claims Act

In which government publication are the details about the various PPS introduced, commented on, and finalized?

Federal Register

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

Fully

The national unadjusted payment amount is the product of the conversion factor multiplied by the relative weight, unadjusted for __________.

Geographic factors

Sal is a Medicare resident in a SNF. Sal has septicemia (serious medical condition I) and depression. His function score is 6. What is the PDPM nursing CMG used in the per diem reimbursement calculation?

HBC2

Jung Hwa was married on July 1, 20XX. She had worked for the organization for the past 8 years and has been covered under its group health insurance policy during the entire period. When can Jung Hwa add her new spouse to her insurance plan?

Immediately, as marriage is a qualifying life event

Why do insurance companies compare E/M levels of service distribution among providers and physician practices?

Insurance companies compare E/M levels of distribution to identify areas of risk. Physicians use a strict set of guidelines to establish levels of service, which allows for comparison among providers and physician practices.

Which of the following is(are) true of CHIP?

It is a federal and state program

The CMI for Memorial Hospital is 1.245. Adding volume to which MS-DRG will increase the CMI?

MS-DRG 164, Major Chest Procedures with CC with a RW of 2.5316

Which MS-DRG includes secondary conditions with a moderate severity of illness? Use the following table to answer question 3.

MS-DRG 194

CMS has increased the weight for MS-DRG A by 14 percent, increased the weight for MS-DRG B by 20 percent, and decreased the weight for MS-DRG D by 10 percent. Given these new weights, which MS-DRG generated the most revenue for Venice Bay Health Center?

MS-DRG C

The MS-DRG that generated the most revenue for Venice Bay Health Center is:Community Hospital collected the data displayed below concerning its four highest volume MS-DRGs.

MS-DRG C

The MS-DRG classification system is hierarchical. Which of the following is the highest level in the hierarchy?

Major Diagnostic Categories

Denial rate is a:

Measure of how well a facility or practice complies with billing rules and regulations for all payers

Discuss how Medicaid is a federal and state program.

Medicaid is a joint program. The federal government has established categories of individuals that must be eligible for Medicaid that apply to every state. Additionally, the federal government establishes a standard set of services that must be provided as benefits by all states. When a state meets the required conditions, it receives federal funds to help administer Medicaid. Each state has the ability to customize its Medicaid program. They may provide benefits beyond the standard set. States may establish cost-sharing or encourage managed care plans. States may also expand their eligibility to more categories of individuals, such as low-income children or adults with dependent children. States supplement the federal Medicaid program funds with state-generated funds.

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

Medicare Claims Processing Manual

The coverage gap, which is a period of expanded cost-sharing, is applicable to which part of Medicare?

Medicare Part D

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 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 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 PDPM component is adjusted by 18 percent to account for the additional resource intensity required to treat residents living with HIV/AIDS?

Nursing

Which of the following software programs is used to execute packaging logic for the Medicare Hospital Outpatient Payment System?

OCE

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

PDPM

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

PT/OT and NTA

Describe how the patient-driven payment model (PDPM) assigns residents to payment categories based on individual patient characteristics. Include at least three factors as evidence.

PT/OT clinical categories PT/OT function score SLP clinical categories SLP-related comorbidities SLP presence of swallowing disorder, mechanically altered diet, and/or cognitive impairment Nursing clinical conditions Nursing depression, number of resorative services, and/or function score Nursing use of extensive services NTA extensive services and comorbid conditions (scale use)

Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was cancelled 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 first party in this healthcare reimbursement scenario?

Parents

Which part of the Medicare program does not include a premium?

Part A

Letha is a data analyst at Happy Hospital. She has been asked to look at some reimbursement data for MS-DRG 025, Craniotomy and Endovascular Intracranial Procedures with MCC. MS-DRG 025 has a relative weight of 4.3945. The fully adjusted base rate for Community Hospital is $7,500. Answer the three parts of this question.What is the expected payment rate for MS-DRG 025 for Community Hospital?Letha has identified that 2 percent of the cases for MS-DRG 025 have a payment rate higher than the expected payment rate. What provision(s) under IPPS could be the reason for the higher-than-expected payment rate?Letha has identified that 1.5 percent of the cases for MS-DRG 025 have a payment rate lower than the expected payment rate. What provision(s) under IPPS could be the reason for the lower-than-expected payment rate?

Part one: The expected payment for MS-DRG 025 is $7,500 × 4.3945 = $32,958.75Part two: The outlier or new medical services and technology could be the cause of the higher payment rate because both provisions increase reimbursement at the individual admission level.Part three: The PACT transfer policy could be the cause of the lower payment rate. This policy results in a lower payment for certain MS-DRGs when the patient is transferred to a post-acute care setting.

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

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

Patient; employer

Use the following contract matrix to answer questions 8 through 11. Patient 24571 is seen in the Occupational Therapy (OT) clinic for an initial evaluation of her carpal tunnel surgery recovery. The charges for the visit total $150. Which payer will reimburse the facility the highest amount?

Payer B

Use the following contract matrix to answer questions 8 through 11. Patient 72341 is admitted as an inpatient for delivery. 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.

CMS uses which reimbursement methodology for inpatient psychiatric facility services payment system because a specific payment rate is established for each day of the admission?

Per diem

Which reimbursement methodology is used for the SNF PPS?

Per diem

Why is it important to adjust productivity goals based on the FTE status for physician productivity analysis?

Physician goals must be aligned with their FTE status so that analysts can make apples-to-apples comparisons in their analysis. Failure to adjust for FTE status will put physicians with less than 1.0 FTE status at a disadvantage.

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

Physician hospital visit

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

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

Relative weight

Compare retrospective reimbursement and prospective reimbursement methodologies.

Retrospective reimbursement is based on the actual resources expended to deliver services and is finalized after the services are delivered. Prospective reimbursement is established prior to the healthcare delivery and does not change based on the actual resources expended. In retrospective reimbursement methodologies, the risk is on the payer side because the reimbursement amount is uncertain until after the services are provided. In prospective reimbursement methodologies the risk is on the provider side because the reimbursement amount is determined before the costs are incurred and not adjusted for costs that exceed the reimbursement level.

Describe the concept of revenue integrity.

Revenue integrity is performing revenue cycle duties to obtain operational efficiency, compliance adherence, and legitimate reimbursement. The foundation of revenue integrity is transparency and honesty. This translates to the every day saying, "doing the right thing." The goal of revenue integrity is to produce a claim for reimbursement that is clean, complete, and compliant.

Service-mix index (SM) is used in which clinical setting?

SMI is used for the hospital outpatient setting where the primary classification system is APCs.

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

Services offered to beneficiaries are the same in each state.

Nari is a compliance analyst at University Hospital. She is preparing an audit plan for an upcoming inpatient audit. She has created a list of medical record numbers for inpatient admissions from the last six months. She has selected the first record on the list and then every fifth record thereafter. Which probability sampling technique is Nari using?

Systematic random sampling

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

TRICARE

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

TRICARE- Military Personal VHA- Veterans CHAMPVA- Spouse or Widow

What is the OCE?

The OCE is a software program designed to process data for OPPS pricing and editing of claims.

Which PDPM components utilize a variable day adjustment? How is the adjustment applied for each applicable component?

The PT/OT components and the non-therapy ancillary component each have a variable day adjustment. For the PT/OT components, there is an adjustment factor after day 20. Starting at day 21 the factor decreases from 1.0 to 0.98 and continues to decrease through day 100 all the way down to 0.76. Research showed that the longer the resident stayed, the lower the costs were for physical and occupational therapy. For the NTA compoenet the first 3 days have an adjustment factor of 3.0 becauses costs were found to be higher in the first days of the resident stay. Days 4 through 100 have an adjustment factor of 1.0.

Which RVU element is used in physician productivity analysis?

The WORK element is used in physician productivity analysis because it measures the physicians' work, such as mental effort and judgment, technical skill, physical effort, and psychological stress.

Which of the following statements about retrospective reimbursement is false?

The fewer services performed the greater the potential for increased total reimbursement

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.

Upcoding is:

The fraudulent process of submitting codes for reimbursement that indicate more complex or higher-paying services than the patient actually received

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.

Use the following contract matrix to answer questions 8 through 11. Patient 62316 is admitted as an inpatient for hip replacement following a fall on ice in the school parking lot where he works as a teacher. During his admission, the patient received OT services post-surgery. The LOS was six days. The charges for the encounter are $135,000. Which payer will reimburse the hospital the highest amount?

There is not enough information in the contract matrix to determine reimbursement for this encounter.

Payment status indicator C is used to identify inpatient-only procedures. If these services are not paid under OPPS, how are they reimbursed?

They are paid via IPPS.

Why is the following statement false? "Adding volume to a clinical area will always increase the CMI."

This statement is false because if volume is added to a MS-DRG with a relative weight lower than the facility's CMI, the CMI will decrease, not increase.

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

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

All of the following functions are ways that MCOs work toward their goal of controlling cost except:

Use of evidence based clinical practice guidelines

One managed care concept that has carried over to most insurance plans is utilization management. A key component of utilization management is utilization review. Describe utilization review. Provide an example of when utilization review would be used.

Utilization review is a process that determines the medical necessity of a service and the appropriateness of the setting for the healthcare service in the continuum of care. An example would be a patient that needs to have a coronary artery stent placed. First, the insurance company will determine if the stent placement is medically necessary—for example, for coronary artery disease. Second, the insurance company will determine if the patient is healthy enough to have the stent placed in the same-day surgery unit or if the patient should be admitted as an inpatient because of comorbid conditions or the patient's overall health status.

Cacey is the coding manager at Memorial Hospital. She is working with compliance to prepare an audit plan for an upcoming inpatient medical record audit. Leadership has been stressing the importance of MS-DRG assignment and the CC/MCC capture rate. Therefore, Cacey is choosing a compliance rate calculation methodology where principal diagnosis code and CC/MCC codes are given a higher weight than other codes. Which compliance rate calculation is Cacey planning to use for the audit?

Weighted code over code

SMI calculation is similar to CMI calculation but uses _______ and their associated RWs.

ambulatory payment classification