Deck 7: Reimbursement

Question 1

Title XVIII is the amendment to the Social Security Act that established:

A) Medicare
B) Medicaid
C) Capitation
D) The prospective payment system

Answer 1

Medicare

Question 2

A patient was admitted to an acute care facility for congestive heart failure. The patient stayed in the facility for 3 days. The actual charges incurred were $6,500. The PPS rate is $5,500. The per diem rate is $1,500 per day. For this case, Medicare will most likely pay:

A) $4,500
B) $5,500
C) $6,500
D) None of the above

Answer 2

$5,500

Question 3

What patient attributes are important to grouper assignment?

A) Age and gender
B) Age and length of stay
C) Length of stay and gender
D) Gender and discharge status

Answer 3

Gender and discharge status

Question 4

The patient was admitted to the hospital in congestive heart failure with the approval of the patient's insurer. After 3 days, utilization review, in conjunction with the patient's insurer, informed the physician that there was insufficient documentation in the patient's record to justify further hospitalization and that no additional charges would be reimbursed. Utilization review's action in this case is called:

A) Discharge planning
B) Admission denial
C) Continued stay denial
D) Managed care

Question 5

Which of the following is true about the Resident Assessment Instrument (RAI), used to collect data in skilled nursing facilities?

A) It is only performed at the end of a patient's stay
B) It contains less data than either the UHDDS or the UACDS
C) It includes elements of the Minimum Data Set (MDS 3.0)
D) None of the above

Question 6

Clinical pathways are based on all of the following EXCEPT:

A) Experience
B) Reimbursement method
C) Research
D) Successful outcomes

Question 7

An organization that insures covered lives as well as owns (exerts employer control over) the health care providers is a(n):

A) Health maintenance organization
B) Preferred provider organization
C) Indemnity company
D) Blue Cross organization

Question 8

When hospitals began being reimbursed based on DRG assignment, patient length of stay decreased because:

A) Coding became more timely and accurate.
B) There was a financial incentive to discharge patients sooner.
C) Patients were less sick.
D) All of the above are correct.

Question 9

The physician charged the patient $75 for an office visit. The patient paid the physician $5 and the patient's insurance company paid the physician $70. The patient's portion of the payment is called:

A) Discounted fee for service
B) Wraparound policy
C) Fee for service
D) Copayment

Question 10

The 82-year-old patient presented in the physician's office for a routine physical examination. He gave the receptionist two cards, evidencing his primary, government-funded insurance plan that pays for most of the bill and an additional, private plan that covers the remaining charges. The patient's secondary insurance is called:

A) Discounted fee for service
B) Wraparound policy
C) Medicare
D) Capitation

Question 11

One major difference between a PPO and an HMO is:

A) Under PPOs, patients can choose any health care provider without penalty
B) HMOs require co-pays
C) HMOs do not typically reimburse for out-of-network providers
D) PPOs require co-pays

Question 12

A patient was treated by his primary care physician. Upon leaving the office, the patient gave the physician a $10 co-pay. This patient's insurance plan is most likely a(n):

A) Indemnity plan
B) Managed care plan
C) Prospective payment plan
D) Group practice model

Question 13

The payment rate established by an insurance company, based on its knowledge of the regional charges for a service, is called:

A) Discounted fee for service
B) Fee for service
C) Usual and customary fees
D) Capitation

Question 14

An HMO contracted with a group of physicians to provide health care services to its members. This is characteristic of a(n) _____ model HMO.

A) Staff
B) Group practice
C) Independent practice association
D) All of the above

Question 15

Under normal circumstances, prospective payment systems take into consideration all of the following EXCEPT:

A) Actual current charges
B) Diagnosis
C) Historical average charges
D) Procedures (treatments)

Question 16

A contractor who manages health care claims for Medicare is a:

A) Blue Cross/Blue Shield organization
B) Fiscal intermediary
C) Medicare PPO
D) Wrap-around policy

Question 17

The department in a hospital that is primarily responsible for submitting bills or claims for reimbursement is:

A) Health information management
B) Utilization review
C) Patient registration
D) Patient accounting

Question 18

Patients are "grouped" into the same DRG because they have all of the following criteria in common EXCEPT similar:

A) Diagnosis
B) Resource intensity
C) Treatment
D) Length of stay

Question 19

Which of the following is NOT a way in which managed care organizations may influence and/or control the patient's choices in selecting health care services:

A) The patient's PCP must be a participating provider.
B) Only approved services may be reimbursed.
C) The managed care organization decides what services are "medically necessary."
D) The managed care organization only pays for services provided by the PCP.

Question 20

The major benefit of a flexible benefit (medical savings) account is:

A) Funds are set aside on a pretax basis.
B) Nondisbursed funds are rolled over to the next year.
C) It enables employees to participate in an HMO.
D) It decreases health care costs.

Question 21

Insurance policies that supplement Medicare coverage are called _________.

Question 22

The federal law that established Medicare PPS is __________.

Question 23

It is the coder's responsibility to assign codes completely and accurately so that a facility receives the reimbursement to which it is entitled. To meet this responsibility, a coder must:

A) Follow all software prompts that will add a "cc" code. The software program is written so that the coder does not have to review the medical record.
B) Use coding software to sequence the best principal diagnosis for the highest reimbursement.
C) Code and sequence according to the documentation in the medical record, using the software only to assist this process.
D) do both a and b.

Question 24

All of the following statements about APCs are true EXCEPT:

A) Patients may be assigned to more than one APC for an encounter.
B) APC assignment is based on ICD-10-CM principal diagnosis and secondary codes.
C) There are over 1,000 APCs.
D) APCs apply only to ambulatory care.

Question 25

A hospital's case mix index is derived by:

A) Organizing each DRG by rank, with the patients in the most frequently occurring DRG listed as #1, and so forth
B) Adding all DRG relative weights together and then dividing by the total number of cases discharged in a given time period
C) Neither a nor b; case mix index is assigned by the federal government using special software
D) Both a and b

Question 26

A patient presented to a hospital three times in one month: one visit was for a throat culture in the clinic. One visit was for a suture of a laceration in the emergency department. One visit was for a same-day stay for a hernia repair. The hospital would submit:

A) One bill at the end of the month totaling all charges under one account number and one medical record number; a new account number would be assigned next month
B) One bill for the throat culture under one account number, and another bill with another account number for the suture and hernia repair, because these were surgical procedures to be grouped together; both bills would have the same medical record number
C) A separate bill for each visit with a new medical record number and new account number
D) A separate bill for each visit with the same medical record number but different account numbers

Question 27

The Medicare patient presented to the emergency department with exacerbation of COPD. The patient was treated and released. The emergency department charges were $430. Two days later, the patient returned to the emergency department with congestive heart failure. The length of stay for the admission was 2 days. The inpatient charges were $4,700. The DRG amount was $3,500. The hospital should bill Medicare for:

A) $3,500
B) $3,730
C) $4,700
D) $5,130

Question 28

Referring to health care provider fees, the rate established by an insurance company, based on the regional charges for the particular service, is called ___________.

Question 29

The amendment to the Social Security Act that established Medicaid is _________.

Question 30

Periodic payments to an insurance company for coverage (an insurance policy) are called _________.

Question 31

Major Diagnostic Categories (MDCs) usually consist of which two main sections?

A) Principal diagnosis and principal procedure
B) With or without secondary diagnosis "CC" codes
C) Medical partitioning and surgical partitioning
D) With or without organ transplant

Question 32

A managed care organization that contracts with a network of health care providers to render services to its members is a ___________.

Question 33

Why would a coder or coding manager automatically review and/or revise patients assigned to DRG 469 and/or DRG 470?

A) The hospital might not be entitled to the reimbursement for these DRGs.
B) The federal government reviews these DRGs for fraud and abuse.
C) There is something incorrect with the codes assigned and/or data when a patient is grouped into either of these DRGs.
D) Both a and b are true.

Question 34

The basis for payment for skilled nursing facility (SNF) services for Medicare patients is:

A) RUGs
B) RBRVS
C) MDS
D) UHDDS

Question 35

The system of exchanging professional services instead of paying for services in cash is called ____________.

Question 36

If a facility is to receive reimbursement for an item such as an aspirin, the item and the cost of the item must be included in the facility's:

A) Chargemaster
B) Codemaster
C) Medical record
D) Encounter form

Question 37

The amendment to the Social Security Act that established Medicare is __________.

Question 38

A specified dollar amount for which the patient is personally responsible, before the payer reimburses for any claims, is called the __________.

Question 39

A savings account in which health care and certain child care costs can be set aside and paid using pretax funds is a __________.

Question 40

The type of insurance that assumes the payment for all or part of certain, specified services, but requires out-of-pocket deductibles and frequently caps total covered payments is called _____________.

Question 41

The party that assumes the risk of paying some or all of the cost of providing health care services in return for the payment of a premium by or on behalf of the individual is the ___________.

Question 42

The process of determining the most accurate DRG payment is ___________.

Question 43

The exchange of cash for professional services rendered, at a rate less than the normal fee for the service, is called ___________.

Question 44

Prospective payment for acute care is based on ____________.

Question 45

The exchange of cash, goods, or services for professional services rendered at a specific rate, typically determined by the provider, and associated with specific activities (such as a physical examination) is called __________.

Question 46

The coordination of the patient's care and services, including reimbursement considerations, is characteristic of ___________.

Question 47

ICD-10-CM diagnosis and procedures codes are used to derive the DRG by following the flowchart in a ___________.

Question 48

The potential exposure to loss, financial expenditure, and/or other undesirable events is called _________.

Question 49

Any of several reimbursement methods that pay an amount predetermined by the payer, based of the diagnosis, procedures, and other factors (depending on setting) rather than actual, current resources expended by the provider, is called ________.

Question 50

To standardize and facilitate accurate billing, health care facilities maintain a database of all potential services to a patient called a _________.

Question 51

The application to an insurance company for reimbursement is called the ______________.

Question 52

The systematic reimbursement to a health care provider based on the number of patients contractually in the physician's care, regardless of diagnoses or services rendered, is called ___________.

Question 53

The blending of the insurance and provider roles in health care delivery is characteristic of _________.

Question 54

A ______________ is a type of third party payer arrangement in which an individual is responsible for a percentage of the amount owed to the provider.

Question 55

The systematic collection of specific charges for services rendered to a patient is called ___________.

Question 56

Medicare uses __________ to process its claims and reimbursements.

Question 57

Payments calculated based on the number of days are called ____________.

Question 58

The process of evaluating medical interventions against established criteria, based on the patient's known or tentative diagnosis, is called ____________.

Question 59

CMS's prospective payment system for hospital-based ambulatory care is based on ___________.

Question 60

Medicare is a federal funded program available to those age 65 and older and those on permanent disability. However, there are many different programs that Medicare offers that are called Parts. How many parts does Medicare have and what services are offered? What does the federal program pay for and what is the patient responsible for?

Question 61

Match the following terms with their definitions.
a. Beneficiary
b. Claim
c. Deductible
d. Fiscal intermediary
e. Payer
f. Benefit
1. Amount of cost that the beneficiary must incur before the insurance will assume liability for the remaining cost
2. Contractor that manages the health care claims, particularly for government-funded programs
3. One who is eligible to receive or is receiving benefits from an insurance policy or a managed care program
4. Party who is financially responsible for reimbursement to providers of health care costs for services rendered
5. Payer's payment for specific health care services or, in managed care, the health care services that will be provided or for which the provider will be paid
6. Request for payment by the insured or the provider for services covered

Question 63

Match the definition with the health insurance terminology.
a. Medicare
b. HMO
c. Capitation
d. Medicaid
e. MS-DRG
f. PPO
7. A uniform reimbursement to a health care provider based on the number of patients contractually in the physician's care, regardless of diagnoses or services rendered
8. A federally mandated, state-funded program providing access to health care for the poor and the medically indigent
9. A managed care organization that contracts with a network of health care providers to render services to the PPO's members
10. A federally funded health care insurance plan for the elderly and for certain categories of chronically ill patients
11. A collection of health care descriptions organized into statistically similar categories
12. A managed care organization characterized by the ownership or employer control over the health care providers

Question 64

Why is the MDS for LTC so different from the UHDDS?

Question 66

Explain the difference in healthcare coverage between an HMO and PPO for the patient.

Question 67

After assignment of the MDC, what occurs next in the grouping process?

Question 68

How would someone use an unbilled list (DNFB)?

Question 69

Discuss Medicaid, including administration and eligibility.

Question 70

Describe how a case is assigned to a Major Diagnostic Category.

Question 71

What is meant by "resource intensity"?

Question 72

Health care insurance involves the assumption of the risk of financial loss by a party other than the patient. Describe how insurance companies can afford to assume such risk.

Question 73

List and describe the four types of reimbursement.