Payer A Show Payer B Payer C Payer D 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?
Terms in this set (127)Who is the third party payer in healthcare situations? c. payer Insurance companies pool premium payment for all the insureds in a group, then use actuarial data to calculate the group's premiums so that which of
the following occur? b. the pool is large enough to pay losses of the entire group The process of completing all the steps that the facility or provider must take to ask for reimbursement from the payer and to ensure that the received
payment is correct? b. revenue cycle What combines the revenue cycle for different types of services into one process. This becomes complicated when there are multiple payment systems involved. But there are benefits to the implementation of this concept including reducing cost, making procedures consistent and focusing on strategic goals
that benefit the organization? c. integrated revenue cycle What is completing one's assigned tasks by following the provided procedure and following all rules? a. revenue integrity In
this healthcare delivery model, the government is the only payer that funds universal healthcare coverage through taxes: c. national health service model In this healthcare delivery model, the insurance company determines that contribution amount that is not based on the policyholder's
income: b. private health insurance model In this healthcare delivery model, employees and employers contribute an income-based amount of money to funds that are regulated by the government: c. social insurance model The US healthcare sector represents a significant portion of the US economy. The trend of ____ spending on healthcare has been consistent for more than a decade. b. increased An employee paying for 40 percent of the insurance premium
through payroll processing is an example of a transaction between ____ and ____ d. patient, employer A physician office submitting an invoice for payment when the patient has health insurance is an example of a transaction between ____ and ____. a. provider, third-party payer 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 healthcare insurance through the mother's employment at the State Department of Treasury. Who is the first party in this healthcare reimbursement scenario? parents 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 healthcare insurance through the mother's employment at the State Department of Treasury. Who is the second party in this healthcare reimbursement scenario? Dr. Gilbert 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 healthcare insurance through the mother's employment at the State Department of Treasury. Who is the third party in this healthcare reimbursement scenario? insurance company Which of the following is true about APCs? a. clean, complete, and complaint Successful RCM programs use this type of approach, which promotes collaboration among various clinical departments and emphasizes education strategy for all members: d. multidisciplinary model Which of the following is not a principle of revenue integrity? b. no oversight Which of the following is a key factor in establishing
highly ethical culture promoting honesty and openness? c. transparency Which of the following is not a component of the revenue cycle? a. revenue calculation The amount paid to a healthcare provider for services provided to a patient reimbursement The amount of money that must be periodically paid to a health insurance company in return for healthcare coverage premium Person who is responsible for paying the bill for healthcare services guarantor An individual who is eligible for benefits from a health plan beneficiary Individual who purchases health insurance coverage policy maker Reduction of a person's exposure to risk of loss by having another party assume the risk insurance Insurance company or health agency that pays the provider for the care or services provided to the patient third-party payer Amy's Summary of Benefits and Coverage (SBC) indicates that she must pay 20 percent for laboratory tests. This is an example of a _____ limitation. a. coinsurance What Medicare part covers Medicare drug benefits? d. Part D What Medicare part covers physician services? b. Part B What Medicare part covers inpatient hospital service? a. Part A What Medicare part covers Medicare Advantage? c. Part C What TRICARE health plan covers ADFM aged 21-25 years old? d. TRICARE Young Adult What TRICARE health plan is a traditional insurance plan for ADFMs (non-managed care)? c. TRICARE Select What TRICARE health plan is a managed
care for ADSMs and ADFMS? b. TRICARE Prime What TRICARE health plan is a secondary payer for Medicare Part A and B eligible beneficiaries? a. TRICARE for Life 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? d. risk pool 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? d. spouse; natural child, age 12; and adopted child, age 8 Jung Hwa was recently married on July 1, 2018. She had worked for the organization for the past eight years and has been covered under its group healthcare insurance policy during the entire period. When can Jung Hwa add her new spouse to her insurance plan? b. immediately, as marriage is a qualifying life event All of the following occurrences are considered "qualifying life events" except d. car accident All of the following types of procedures and services typically require prior authorization except: a. emergency services for suspected stroke Which of the following characteristics
is the greatest advantage of group health insurance? c. greater benefits for lower premiums All of the following functions are ways that MCOs work toward their goal of controlling cost except: a. use of evidence based clinical practice guidelines Which of the following activities are utilized as financial incentives by MCOs? c. productivity (number of visits per day) All of the following activities are steps in medical necessity and utilization review except: d. administrative review All of the following activities are service management tools used in controlling costs except: a. applying an episode-of-care payment system Juan belongs to a managed care plan. He wants to make an appointment with an out-of-network specialist. The plan has approved the appointment as "out-of-network." What should Juan expect? a .The front office of the out-of-network specialist will delay and obstruct the making of the appointment. b. The patient's out-of-pocket costs for the out-of-plan appointment will be equal to the out-of-pocket costs for in-plan care because the prior notification was completed c. The patient's out-of-pocket costs will be increased d. The patient can permanently transfer his or her care to the out-of-plan specialist because the initial appointment was approved. c. The patient's out-of-pocket costs will be increased What is the term that means evaluating, for a healthcare service, the appropriateness of its setting and its level of service? b. utilization review For what type of care should
the physician practice manager expect to work with a case manager? d. workers compensation Insurance policies include procedures for the determination of other party liability (OPL). When a(n) ____ is involved, the insurance company will need to perform a determination of other party liability. b. automobile insurance Managed care plans control beneficiary choice of provider. On the continuum of control, which type of managed care organization has the most control and, therefore, has the greatest limitations on a beneficiary seeing a provider that is not in network? a. health maintenance organization Once the maximum out-of-pocket benefit is activated, all covered healthcare services for that policyholder or beneficiary are paid at 100 percent by the health insurance plan. The policyholder is not liable for _____ beyond the maximum out-of-pocket amount. d. cost sharing amounts 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? c. premium Which part of
the Medicare program does not include a premium? a. part a The coverage gap, which is a period of expanded cost-sharing, is applicable to which part of Medicare? d. medicare part d Medicaid
is a joint program between ___ and ____ governments? b. federal and state Which government-sponsored program provides coverage for active-duty service members of the armed forces (ADSM)? a. TRICARE Which government-sponsored program is designed to provide managed care to the frail elderly population? c. program of all-inclusive care for the elderly (PACE) Which
of the following is not a function of the Indian Health Service (IHS)? c. provides only inpatient healthcare services The
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is available for: b. spouse, widow(er), or children of a veteran meeting specific criteria Which of the following is(are) true of
CHIP? a. it is a federal and state program Which of the following statements about the Veterans Health Administrator (VA) is false? b. basic eligibility includes all veterans who served in active military service regardless of the separation condition Medicare part C is a _____ option known as Medicare
Advantage. a. managed care All of the following are true of state Medicaid programs except: d. services offered to beneficiaries are the same in each state In states where there is not a mandated fund for workers' compensation which of the following is an option for employers? b. purchase workers' compensation insurance from a private carrier Which of the following is a service that is excluded from Medicare Part A and Part B, but may be provided under Part C? c. eye exams including contacts and eyeglasses Which of the following statements about retrospective reimbursement is false? c. the fewer services performed the greater the potential for increased total reimbursement 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 uses to reimburse Dr. Jones? b. global payment method 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? c. capitation 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? a. fee schedule 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? d. case-rate methodology CMS uses this reimbursement methodology when they contract with Medicare Advantage Payers to care for Medicare beneficiaries
under Medicare Part C. a. capitation The CMS-HCC model uses ____ and _____ to predict the patient's healthcare costs. a. patient demographic characteristics; health status In the CMS ACO model, what is attribution? c. a beneficiary is assigned to a particular ACO Giant ACO has agreed to a shared savings rate if 65 percent and a shared loss rate of 40 percent with CMS. Giant ACO participates in a ____ risk agreement b. two-sided 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? b. per diem 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? a. determine the MDC for the principal diagnosis Eli 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? c. determine if any procedure reported, principal or secondary, is an OR procedure in the MS-DRG Definitions Manual Which of the following concepts is a guiding principle for prospective payment? d. payment rates are established in advance of the healthcare delivery and are fixed for the fiscal period to which they apply What is the basis of the "labor-related share"? d. facilities' costs related to payrolls, benefits, and professional fees Which of the following statements about the IPPS high-cost provision is false? b. the outlier payment ensures that hospitals will not experience a financial loss for the encounter In which government publication are the details about
the various PPS introduced, commented on, and financial? a. federal register The MS-DRG payment includes reimbursement for all of the following inpatient services except: a. physician hospital visit 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? c. determine if the coronary artery bypass procedure is one of the pre-MDC procedures 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? a. the first hospital receives a per-diem payment derived from the potential MS-DRG and the second hospital receives the full MS-DRG In MS-DRG, the case-mix index is a proxy for what? c. consumption of resources The
post-acute care transfer policy treats ____. d. type 2 transfers like type 1 transfers for certain MS-DRGS Jameson is calculating the MS-DRG for inpatient admission. He is determining if the encounter is medical or surgical. Which of
the following should he do? c. determine if any procedure coded is designated as on OR procedure in the MS-DRG The MS-DRG classification system is hierarchical. Which of the following is the highest level in the hierarchy? d. major diagnostic categories Which reimbursement methodology is used for the SNF PPS? b. per diem Skilled nursing facility services are covered under Medicare Part A. Under this benefit, Medicare beneficiaries are eligible for up to ____ days of SNF-covered services per benefit period? b. 100 Which of the following PDPM components of care
is not adjusted by characteristics of the resident? a. non-case-mix The variable day adjustment policy is applied to which PDPM components? d. PT/OT and NTA Which
PDPM component is adjusted by 18 percent to account for the additional resource intensity required to treat residents living with HIV/AIDS? c. nursing Which of the following statements about SNF per diem payment is false? b. there is only one per diem rate per resident stay Which answer displays the correct order of steps for per diem payment determination? d. choose base rate; wage index adjust; adjust for case mix; adjust for day of stay; sum the components CMS withholds of SNF PPS payments to fund the Nursing Facility VBP
Program? b. 2 percent What percent of the withhold is redistributed to high-performing SNFs under the Nursing Facility VBP Program? c. 60 percent For the five PDPM components that are adjusted for
resident's characteristics, the CMG assigned for the resident has an associated __ that is a proxy for resource intensity. a. case-mix index In Medicare's prospective payment system for skilled nursing facilities, what classification model is used to adjust for case mix? a. CMGs Which of the following does not impact the CMG used in the SNF Services Payment System? a. Number of therapy hours per week APC Payment K C-APC J1 Composite APC Payment Q3 Conditional APC Payment Q4 Which of the following SIs are the highest ranked SI and causes all other services to be packaged on a claim? c. J1 Which type of service includes an APC per diem methodology that includes payment for all services provided on a single day of service under OPPS? b. partial hospitalization Which of the following reimbursement
methodologies is not utilized in the Outpatient Hospital Services Payment System? c. percent of billed charges Reimbursement for minor ancillary services associated with a significant procedure are combined into a single payment for the procedure. This is the definition of ___ a. packaging The methodology used for critical care services, imaging, and mental health services that results in composite APCs is ___. b. bundling The APC system is a ____ packaged system, therefore
___ APC can be assigned per encounter? d. partially, more than 1 Which of the following software programs is used to execute packaging logic for the Medicare Hospital Outpatient Payment System? c. OCE Under
the OPPS, outpatient services that are similar both clinically and in use of resources are assigned to separate groups called ____. b. APCs Which of the following statements is true about APCs? d. APCs are based on the CPT or HCPCS code(s) reported Which of the following status indicators that the APC payment is reduced when multiple procedures with this status are reported together? c. T-surgical procedures Which APC component is a measure of the resource intensity of a particular procedure or service? c. relative weight Payment status indicator C is used to identify inpatient-only procedures. If
these services are not paid under OPPS, how are they reimbursed? d. they are paid via IPPS The national unadjusted payment amount is the product of the conversion factor multiplied by the relative weight, unadjusted for ___. c. geographic factors CMS created Comprehensive APCs with the goal of moving toward a ____ packaged outpatient PPS. a. fully Conditional APCs include services that are conditionally packaged
only when certain criteria are met. Conditional APCs with status indicators Q1 are packed when a service with which the following status indicator(s) are also reported on the same encounter? b. s, t, or v Which of the following modifiers is included in the interrupted service provision under OPPS? d. 73 In this methodology, a predetermined payment amount is paid to the provider for all services required for a pre-defined condition and time frame. bundled payment In this methodology, the payer reimburses the provider a single amount to cover all applicable services provided for an established time frame. global payment In this methodology, the payer reimburses the provider a set dollar amount for the patient for each month that the patient is under the care of the provider. capitation In this methodology, the payer has negotiated to pay a reduced amount instead of the full charge for a healthcare service. percent of billed charges In this methodology, the payer reimburse the provider for each day of care rather than for each service provided to the patient. per diem In this methodology, the payer reimburse an amount for each service, supply or procedure according to a predetermined list of rates. fee schedule
In this methodology, the payer reimburses the provider a single payment amount for all care provided during an admission or encounter regardless of the volume of services or total cost of care. case rate Sets found in the same folderUNDERSTANDING HEALTH INSURANCE CHAP 1630 terms THBARNETT9912 understanding health insurance chapter 1514 terms Babygirl8589 Understanding Health Insurance CH. 12,13&1442 terms Natalie_Skinner33 Understanding Health Insurance - Chapter 678 terms Mark_Koehl7 Other sets by this creatorDomain 354 terms lexipage24 CPC Practice29 terms lexipage24 Domain 290 terms lexipage24 Domain 1101 terms lexipage24 Verified questions
economics Express each logarithmic form exponentially and each exponential form logarithmically. $32^{3 / 5}=3$ Verified answer
finance Sue Hartley recently accepted a job in the production department at **Tootsie Roll**. Before she starts work, she decides to review the company’s annual report to better understand its operations. ***Instructions*** Use the annual report provided in Appendix A to answer the following questions. (i) What was the value of raw material and supplies inventory in 2010? Verified answer algebra Evaluate the expression. $$ \dfrac{12^3}{12^3} \cdot 75^2 $$ Verified answer
question Refer to Example 11.2. Create a table that shows the effect on the test statistic and the p-value of changing the value of the sample mean. Use $\bar{X}$ = 15.0, 15.5, 16.0, 16.5, 17.0, 17.5, 18.0, 18.5, and 19.0. Verified answer Recommended textbook solutions Information Technology Project Management: Providing Measurable Organizational Value5th EditionJack T. Marchewka 346 solutions
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Information Technology Project Management: Providing Measurable Organizational Value5th EditionJack T. Marchewka 346 solutions
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