Deck 16: Reimbursement Methodologies

Question 1

All managed care plans have primary care providers.

Answer 1

True

Question 2

Reimbursement methodologies are the theories and practices utilized to pay for the services provided by health care professionals.

Answer 2

True

Question 3

The change in reimbursement methodologies has redirected the focus from a treatment perspective to a financial perspective.

Answer 3

True

Question 4

Coverage refers to those health care services that have previously been identified as reimbursable under the insurance plan.

Question 5

Managed care refers to health plans that integrate fully the financial and delivery aspects of health care.

Question 6

Relying on usual, customary, and reasonable costs were an attempt to control costs under managed care.

Question 7

In the fee-for-service payment methodology, the prices are predetermined before delivery of service.

Question 8

A primary care provider (PCP) is the physician who serves as the gatekeeper or coordinator for all of the patient's care.

Question 9

Medicare Part B covers inpatient hospitalization.

Question 10

The Medicaid program is designed to provide financing for poor and impoverished persons.

Question 11

The initiation of DRGs resulted in a significant cost savings to Medicare.

Question 12

Employers use HEDIS to compare health plans.

Question 13

Despite severe criticism of capitation, the practice has continued to grow.

Question 14

Under managed care, the contract for independent multispecialty medical providers includes significant financial incentives for the physicians to provide proper patient care and financial management.

Question 15

Third-party payers operate at only nongovernmental levels.

Question 16

The efficient management of reimbursement systems is critical if the organization's mission and financial goals are to be met.

Question 17

Managed care began as an outgrowth of the Health Maintenance Organizations Act of 1963.

Question 18

To make the fee-for-service system work, Medicare adopted the Diagnosis-Related Group (DRG).

Question 19

TRICARE is for active duty members of the uniformed services.

Question 20

Third-party payers are organizations or entities that are willing to pay for health care services rendered the patient by the health care provider.

Question 21

Which factors greatly influenced the growth of managed care?

A) inflation and legislative changes
B) change in the demands of patients
C) widespread bankruptcies being filed
D) lawsuit actions

Question 22

Medicare Part C covers prescription drugs.

Question 23

Which of the following practices were common with the fee-for-service plan?

A) developing of a chargemaster
B) balance billing for uncovered charges
C) unbundling to increase costs per item
D) retrospective payment system
E) all of the descriptors apply to the fee-for-service plan

Question 24

Which of the following is true about managed care?

A) It is based solely on financial criteria.
B) It is steadily on the decline.
C) It is a method used to assume and transfer risk.
D) They are second-party payors.

Question 25

Which of the following is the best definition for the insured?

A) the insurance company that agrees to pay for health care
B) the one holding the insurance policy
C) the prepayment of a specified amount for health care coverage
D) The insured includes the private insurance companies, employers, and managed care organizations.

Question 26

Which of the following statements is true about the BCBS (Blue Cross Blue Shield) Association

A) It is the single largest trade association of private health care insurers in the United States.
B) It covers hospital and related services only.
C) It covers physician services only.
D) It is a for-profit organization.

Question 27

A preferred provider organization (PPO) requires patients to go through a gatekeeper to see a specialist.

Question 28

All of the following are eligibility requirements for Medicare EXCEPT

A) must be 65 years and older.
B) diagnosis of end stage renal disease.
C) below the federal poverty level.
D) disabled.

Question 29

Part _____ of Medicare includes the new Medicare Advantage options.

A) A
B) B
C) C
D) D

Question 30

Which of the following would be considered a third-party payer?

A) The patient
B) The provider or institution providing care
C) The organization paying for the care
D) The laboratory services

Question 31

Which of the following is a payment methodology that is set by a formula for a set amount, regardless of quantity or nature of services rendered?

A) fee-for-service
B) prospective payment system
C) resource-based relative value system
D) capitation

Question 32

What is the HIPAA rule that requires covered entities who transmit certain patient data electronically to use specific electronic transactions and code sets?

A) HIPAA Security Rule
B) HIPAA Privacy Rule
C) HIPAA Transactions Rule
D) HIPAA Code Set Rule

Question 33

Workers' Compensation programs compensate employees immediately for lost wages due to work-related injuries and illnesses.

Question 34

Which of the following refer to the efficient and effective use of administrative and clinical functions to capture, manage, and collect revenue related to the delivery of patient services?

A) revenue cycle management
B) control management
C) management by objectives
D) financial management
E) cash flow management

Question 35

How many days of skilled nursing care are covered under Part A?

A) 30
B) 60
C) 90
D) 100

Question 36

When a health care facility was required to justify to a state agency the need to purchase new equipment, buy or create new buildings, or offer new services, it was called

A) cost allocation
B) certificate of need program
C) expansion request report

Question 37

Which of the following statements apply to resource-based relative value scale systems?

A) They were developed by private insurance payors to help control costs.
B) They are a DRG-type system for reimbursement of physician services.
C) The physicians submit their usual and customary charges, which form a basis of payment.
D) All of the descriptors apply to a resource-based relative value scale system.

Question 38

Part _____ of Medicare helps pay for physician and outpatient charges.

A) A
B) B
C) C
D) D

Question 39

An HMO is only one form of managed care.

Question 40

Inflation refers to the persistent rise in the average level of prices.

Question 41

Match the type of health care reimbursement program with its descriptor.
covers veterans of the armed services who are permanently and totally disabled

A)Medicare Part A
B)Medicare Part B
C)Medicare Part C
D)Medicare Part D
E)Medicaid
F)TRICARE
G)CHAMPVA
H)worker's compensation
I)IHS

Question 42

Match the managed care term with its descriptor.
prepaid, organized system for providing comprehensive health care services within a geographic area to all persons under contract

A)HMO
B)closed-panel arrangement
C)PPO
D)EPO
E)POS
F)IDA

Question 43

Match the type of health care reimbursement program with its descriptor.
covers inpatient hospital care and long-term care for those over 65 years of age

A)Medicare Part A
B)Medicare Part B
C)Medicare Part C
D)Medicare Part D
E)Medicaid
F)TRICARE
G)CHAMPVA
H)worker's compensation
I)IHS

Question 44

Part _____ of Medicare helps pay for prescription drugs.

A) A
B) B
C) C
D) D

Question 45

Three accrediting bodies address managed care organizations EXCEPT

A) NCQA.
B) HEDIS.
C) JC.
D) AAAHC.

Question 46

. In what year did Congress pass the Tax Equity and Fiscal Responsibility Act (TEFRA)?

A) 1980
B) 1982
C) 1985
D) 1987

Question 47

Match the type of health care reimbursement program with its descriptor.
covers prescription care for those over 65 years of age

A)Medicare Part A
B)Medicare Part B
C)Medicare Part C
D)Medicare Part D
E)Medicaid
F)TRICARE
G)CHAMPVA
H)worker's compensation
I)IHS

Question 48

What is an Explanation of benefits (EOB)?

A) Statement sent to the health care provider and the patient explaining what the third party paid.
B) Statement sent to the health care provider and the patient explaining what the patient owes.
C) Statement sent to the health care provider explaining what the third party paid.
D) Statement sent to the patient explaining what the patient owes.

Question 49

Match the type of health care reimbursement program with its descriptor.
expanded coverage for those over 65 years of age

A)Medicare Part A
B)Medicare Part B
C)Medicare Part C
D)Medicare Part D
E)Medicaid
F)TRICARE
G)CHAMPVA
H)worker's compensation
I)IHS

Question 50

Match the type of health care reimbursement program with its descriptor.
provides health services to native American Indians & native Alaskans

A)Medicare Part A
B)Medicare Part B
C)Medicare Part C
D)Medicare Part D
E)Medicaid
F)TRICARE
G)CHAMPVA
H)worker's compensation
I)IHS

Question 51

Match the type of health care reimbursement program with its descriptor.
program designed to provide financing for the poor and impoverished

A)Medicare Part A
B)Medicare Part B
C)Medicare Part C
D)Medicare Part D
E)Medicaid
F)TRICARE
G)CHAMPVA
H)worker's compensation
I)IHS

Question 52

Match the type of health care reimbursement program with its descriptor.
covers active-duty members of the armed services

A)Medicare Part A
B)Medicare Part B
C)Medicare Part C
D)Medicare Part D
E)Medicaid
F)TRICARE
G)CHAMPVA
H)worker's compensation
I)IHS

Question 53

Match the type of health care reimbursement program with its descriptor.
covers employees who suffer work-related injuries and illnesses

A)Medicare Part A
B)Medicare Part B
C)Medicare Part C
D)Medicare Part D
E)Medicaid
F)TRICARE
G)CHAMPVA
H)worker's compensation
I)IHS

Question 54

Match the type of health care reimbursement program with its descriptor.
covers physician fees, outpatient hospital services, and home health care services for those over 65 years of age

A)Medicare Part A
B)Medicare Part B
C)Medicare Part C
D)Medicare Part D
E)Medicaid
F)TRICARE
G)CHAMPVA
H)worker's compensation
I)IHS

Question 55

The ______________________ ______________________ ______________________ is the physician who serves as the gatekeeper or coordinator for all the patient's care.

Question 56

The Federal Employment Compensation Act (FECA) provides workers' compensation for

A) military federal employees.
B) nonmilitary federal employees.
C) military nonfederal employees.
D) nonmilitary nonfederal employees.

Question 57

Part _____ of Medicare helps pay for charges incurred during an inpatient hospital stay.

A) A
B) B
C) C
D) D

Question 58

The most powerful of third-party payors is the ______________________ ______________________.

Question 59

The RBRVS (resource-based relative value scale) system uses a coding system for typical procedures that can be done in the physician's office. This coding system is called ______________________.

Question 60

There are _____ parts to the Medicare Program.

A) ONE
B) TWO
C) THREE
D) FOUR

Question 61

Define unbundling.

Question 62

Explain the difference between Fee for Service and Capitation.

Question 63

Match the managed care term with its descriptor.
similar to a PPO except that the patient must stay within the provider network to receive care

A)HMO
B)closed-panel arrangement
C)PPO
D)EPO
E)POS
F)IDA

Question 64

Explain the difference between HMO and PPO.

Question 65

Match the managed care term with its descriptor.
physicians employed by an HMO can only treat those patients who are members of the HMO plans

A)HMO
B)closed-panel arrangement
C)PPO
D)EPO
E)POS
F)IDA

Question 66

Match the managed care term with its descriptor.
an entity composed of health care providers who contract with an employer or private health insurance company to deliver services at a discounted rate in return for a promise of a high volume of patients

A)HMO
B)closed-panel arrangement
C)PPO
D)EPO
E)POS
F)IDA

Question 67

Match the managed care term with its descriptor.
allows patients to choose the type of provider they will receive care from at or near the point of time the care will be received

A)HMO
B)closed-panel arrangement
C)PPO
D)EPO
E)POS
F)IDA

Question 68

Explain medical necessity.

Question 69

Match the managed care term with its descriptor.
provides coordinated health care services by concentrating on vertical integration

A)HMO
B)closed-panel arrangement
C)PPO
D)EPO
E)POS
F)IDA

Question 70

Describe a certificate of need program?