Deck 17: Reimbursement Procedures: Getting Paid

Question 1

Under Medicare's PPS,long-term care hospitals (LTCHs)generally treat patients who require hospital-level care for an average length of stay greater than _____ days.

A) 10
B) 15
C) 25
D) 60

Answer 1

25

Question 2

Services provided under the hospital outpatient prospective payment system (OPPS)are classified and paid according to:

A) DRGs.
B) ALOS.
C) APCs.
D) PPS.

Answer 2

APCs.

Question 3

The amount of payment in the Prospective Payment System (PPS),based on the classification system of that service,is determined by the assigned:

A) capitation amount.
B) diagnosis-related group (DRG).
C) usual, customary, and reasonable (UCR) fee.
D) either b or c

Answer 3

diagnosis-related group (DRG).

Question 4

When an insurance carrier makes a payment to the patient/insured (or the provider)for a covered expense,it is referred to as:

A) coverage.
B) copayment.
C) deductible(s).
D) reimbursement.

Question 5

The presence of one or more disorders/diseases in addition to the primary disorder/disease is called a:

A) comorbidity.
B) complication.
C) dual diagnosis.
D) medical history.

Question 6

The typical length of stay for a patient classified to a long-term care (LTC)DRG is referred to as the:

A) APC.
B) GPCI.
C) ALOS.
D) ADL.

Question 7

The federal payment rate adjustment for LTCH stays that are significantly shorter than the average length of stay for a long-term care DRG is referred to as:

A) GPCI.
B) ALOS.
C) LTC adjuster.
D) a short-stay outlier.

Question 8

Medicare and Medicaid's patient classification system,consisting of distinct groupings that provide a means for relating the type of patients a hospital treats with the costs incurred for treating them is called:

A) PPS.
B) DRG.
C) RVS.
D) APC.

Question 9

When determining the applicable DRG classification,the key piece of information is the patient's:

A) chief complaint.
B) primary diagnosis.
C) principal diagnosis.
D) underlying symptoms.

Question 10

A computer software program that takes the coded information and identifies the patient's DRG category is called a:

A) descrambler.
B) DRG grouper.
C) DRG identifier.
D) digitalized coder.

Question 11

The basic idea of resource utilization groups (RUGs)is to calculate payments to:

A) outpatient clinics.
B) acute care hospitals.
C) skilled nursing facilities.
D) long-term care facilities.

Question 12

A method of payment for healthcare services whereby the provider is paid a fixed amount for each patient regardless of the actual number or nature of services provided is called:

A) UCR.
B) PPG.
C) capitation.
D) fee-for-service.

Question 13

A system of payment for healthcare services whereby the provider charges a specific fee for each service rendered and is paid that fee by the patient or by the patient's insurance carrier is called:

A) capitation.
B) fee-for-service.
C) discounted fee-for-service.
D) prospective payment system (PPS).

Question 14

Which of the following is not one of the three components that make up the total relative value unit (RVU)?

A) Physician work
B) Patient diagnosis
C) Practice expense
D) Malpractice risk

Question 15

The Prospective Payment System (PPS)is Medicare's system for reimbursing which of the following?

A) Part A inpatient hospital costs
B) Part B physician and outpatient charges
C) Both Part and Part B costs
D) Only emergency room fees

Question 16

A type of reimbursement used by CMS that bases Medicare payments on a predetermined,fixed amount (e.g.,DRGs for inpatient hospital services)is called:

A) capitation.
B) fee-for-service.
C) discounted fee-for-service.
D) prospective payment system.

Question 17

The relative value of each service on Medicare's RVRVS fee schedule is multiplied by the ______________,an annually adjusted conversion factor for each Medicare locality.

A) GPCI
B) ALOS
C) ANSII
D) RBRVS

Question 18

CPT Level I and HCFA Common Procedure Coding System (HCPCS)Level II codes determine the assignment of the individual ___________ payment rate.

A) APC
B) ASCII
C) ICD
D) HCPCS

Question 19

The current Medicare RBRVS physician fee schedule is calculated using the ____________ of the service provided (identified by a CPT code)and based on the resources the service consumes.

A) UCR rate
B) per diem rate
C) relative value
D) resource-based value

Question 20

Several variations of payment systems from the initial PPS currently being used by Medicare and other third-party payers in the United States have been developed by the:

A) Affordable Care Act.
B) Department of Health/Human Services.
C) Social Security Amendments of 1983.
D) Centers for Medicare/Medicaid Services.

Question 21

An agreement between the provider and a third-party payer whereby the provider agrees to accept the payer's allowed fee as payment in full for a particular service or procedure is referred to as:

A) patient equity.
B) balance billing.
C) a prospective payment.
D) a contractual write-off.

Question 22

A system of classifying hospital inpatient cases into categories with similar use of the facility's resources is __________.

Question 23

Define the term "cost outlier."

Question 24

Medicare payment rules are made by the:

A) American Hospital Association (AHA).
B) American Medical Association (AMA).
C) Centers for Medicare and Medicaid Services (CMS).
D) National Uniform Claim Committee.

Question 25

Skilled Nursing Facility (SNF)payment rates are adjusted for _________ and ________________,and cover all costs of furnishing covered SNF services.

Question 26

Each long-term care DRG has a predetermined _________________ or the typical length of stay for a patient classified to the LTC-DRG.

Question 27

The computer software program that takes patients' coded information and identifies the DRG category is called the _____________.

Question 28

Organizations that have the ability to force hospitals to comply with HHS admission and quality standards are called ____________________.

Question 29

The ________________ program employs a CMS hierarchical condition category (HCC)risk assessment payment model.

Question 30

More and more practices are converting to a provider fee schedule that is based on:

A) FFS.
B) RVUs.
C) GPCI.
D) PROs.

Question 31

Name the factors on which the DRG inpatient classification system is based.

Question 32

The process of adjusting or canceling the balance on a patient's account after all deductibles,coinsurance amounts,and third-party payments have been made is called _________.

Question 33

In most cases,the unit of payment under OPPS is determined by the assignment of _____________________ and reimburses a predetermined amount based on similar clinical characteristics and similar costs of the procedure performed.

Question 34

Identify which of the following is the organization (composed of physicians and other healthcare professionals)established by TEFRA to review quality of care and appropriateness of admissions,readmissions,and discharges for Medicare and Medicaid patients.

A) Managed care organization (MCO)
B) Peer review organization (PRO)
C) American Medical Association (AMA)
D) Resource Utilization Group (RUG)

Question 35

Name the three components that make up a relative value unit (RVU).

Question 36

Non-PARs not accepting assignment can charge beneficiaries no more than _____ % of the Medicare allowed fee.

A) 50
B) 75
C) 100
D) 115

Question 37

The acronym for the system designed to explain the amount and type of resources used in an outpatient encounter is ______.

Question 38

A hospital's all-inclusive daily rates,as calculated by department,are referred to as _______.

Question 39

The adjustment for the health condition,or clinical characteristics,and service needs of the beneficiary is referred to as the _______________.

Question 40

A common method of reimbursement used primarily by HMOs where the provider or healthcare facility is paid a fixed,per capita amount for each person enrolled in the plan without regard to the actual number or nature of services provided is called __________.

Question 41

Medicare beneficiaries are the only patients who are included in the prospective payment system (PPS).

Question 42

List the three types of firms that fall under the umbrella of a "covered entity," as named by HIPAA.

Question 43

A patient's DRG categorization depends on the coding and classification of the patient's admitting diagnosis only.

Question 44

Resource utilization groups (RUGs)are used to calculate payments to a SNF according to severity and level of care.

Question 45

Hospitals are paid a set fee for treating patients in a single DRG category under Medicare's PPS,regardless of the actual cost of care for the individual.

Question 46

What format do the transaction standards of HIPAA specify for electronic transactions dealing with healthcare billing and payment?

Question 47

The established payment rate for all services that a patient in an acute care hospital receives is based on the highest payment level experienced in the DRG category.

Question 48

Relative weights (RWs)and arithmetic length of stay (ALOS)both impact DRGs.

Question 49

Explain a "contractual write-off."

Question 50

The DRG reimbursement system is used in both Medicare and Medicaid healthcare programs.

Question 51

Bad debt write-offs are the same as contractual write-offs.

Question 52

Many different computerized patient accounting systems are currently available for medical facilities;all are capable of performing a variety of system functions.List at least five of these functions.

Question 53

When treating a typical inpatient in a given DRG,prospective payment rates are set at a level intended to cover operating costs.

Question 54

Under the hospice payment system,there is a per diem rate for each day of care classified into one of four levels,which are:

Question 55

Also taken into consideration when assigning DRGs is the patient's principal procedure and any additional operations or procedures done during the time spent in the hospital.

Question 56

Before disclosing a patient's protected health information (PHI),except for the purposes of treatment,payment,or healthcare operations,what must the practice obtain?

Question 57

The biggest challenge in developing an RVS-based payment schedule was patient diversity.

Question 58

Although reporting formats vary with different patient accounting software systems,most systems are capable of producing certain standard reports.Name at least five of these standard reports.

Question 59

Congress establishes all Medicare and Medicaid payment rules.

Question 60

The basic idea of RUGs is to calculate payments to a critical care unit.

Question 61

The presence of one or more disorders/diseases in addition to a primary disorder/disease is called a comorbidity.

Question 62

HIPAA declared that ICD-9 diagnosis and procedure codes will be replaced by ICD-10 codes as of October 1,2014.

Question 63

Peer review organizations (PROs)only deal with organizations that involve healthcare.

Question 64

DRG payments for each hospital are adjusted for differences in area wages,teaching activity,care to the poor,and other factors.

Question 65

Most patient accounting systems available today are capable of performing the same basic system functions.

Question 66

HIPAA standards do not address rules related to the format of electronic transactions.

Question 67

The inpatient rehabilitation facility (IRF)PPS is the reimbursement system developed by CMS to cover inpatient rehabilitation services provided to Medicare beneficiaries.

Question 68

Under the inpatient psychiatric facility PPS,federal per diem rates include geographic factors,patient characteristics,and facility characteristics.

Question 69

PPS is Medicare's system for reimbursing Part A inpatient hospital costs,and the amount of payment is determined by the assigned diagnosis-related group (DRG).

Question 70

When a medical practice contracts with a "business associate," unless the business is medically related,the agreement does not have to abide by HIPAA regulations.

Question 71

To qualify for IRF PPS rates,an inpatient hospital must establish that 100% of its patients meet certain criteria for intensive inpatient rehabilitation.

Question 72

It is important to make sure products are in compliance with the HIPAA Privacy Rule when selecting a hardware/software vendor.