Question 1

Each home health resource group (HHRG) has an associated __________ that increases or decreases Medicare's payment for an episode of home health care.

Accepted Answer

The weight value is associated with each HHRG and is used to adjust Medicare's payment for an episode of home health care based on the expected resource use.

Question 2

The MMA of 2003 mandated implementation of a(n) __________ payment amount as a substitute for the Ambulatory Surgical Center (ASC) standard overhead amount for surgical procedures performed at an ASC.

Accepted Answer

The MMA of 2003 mandated implementation of an outpatient prospective payment system (OPPS) as a substitute for the Ambulatory Surgical Center (ASC) standard overhead amount for surgical procedures performed at an ASC.

Question 3

Reimbursement according to a __________ means that hospitals reported actual charges for inpatient care to payers after discharge of the patients from the hospital.

Accepted Answer

The retrospective reasonable cost system involves hospitals reporting actual charges for inpatient care to payers after the patients are discharged, allowing for reimbursement based on the costs incurred.

Question 4

Diagnosis-related groups are organized into mutually exclusive categories called __________, which are loosely based on body systems.

Accepted Answer

Major diagnostic categories are loosely based on body systems.

Question 5

Which is associated with a particular category of patient and is established by the payer prior to the provision of health care services?

Accepted Answer

A prospective price-based rate is established by the payer before services are provided and is associated with a specific category of patient.

Question 6

The inpatient prospective payment system (IPPS) resulted in Medicare reimbursing hospitals for inpatient hospital services according to a __________ rate for each discharge.

Accepted Answer

The IPPS reimburses hospitals based on a predetermined rate for each discharge, which is set in advance and is not based on the actual costs incurred.

Question 7

In 1980 Medicare authorized implementation of ambulatory surgical center __________ rates as a fee to ambulatory surgery centers (ASCs) for facility services furnished in connection with performing certain surgical procedures.

Accepted Answer

Medicare implemented payment rates for ambulatory surgical centers to cover facility services for certain surgical procedures.

Question 8

The Medicare durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) fee schedule reimburses DMEPOS either __________ percent of the actual charge for the item or the fee schedule amount, whichever is lower.

Accepted Answer

Medicare reimburses DMEPOS at 80 percent of the actual charge or the fee schedule amount, whichever is lower, with the remaining 20 percent typically covered by the patient or supplemental insurance.

Question 9

Medicare reimburses laboratory services according to a(n) __________, which is based on the submitted charge, national limitation amount, or local fee schedule amount, whichever is lowest.

Accepted Answer

Medicare reimburses laboratory services based on the Clinical Laboratory Fee Schedule, which considers the submitted charge, national limitation amount, or local fee schedule amount, choosing the lowest of these for reimbursement.

Question 10

The federal government administers several health care programs, some of which require services to be reimbursed according to predetermined reimbursement methodologies, which are established as __________.

Accepted Answer

The federal government uses predetermined reimbursement methodologies known as payment systems to standardize how services are reimbursed across various health care programs.

Question 11

The ambulance fee schedule payment system replaced a __________ for providers and suppliers of ambulance services.

Accepted Answer

The ambulance fee schedule payment system replaced the retrospective reasonable cost payment system, which was based on the actual costs incurred by providers and suppliers.

Question 12

Home health resource groups are reported to Medicare on UB-04 using the __________ code set, which represents case-mix groups about which payment determinations are made for the home health prospective payment system.

Accepted Answer

HIPPS (Health Insurance Prospective Payment System) codes are used to represent case-mix groups for payment determinations in the home health prospective payment system.

Question 13

Which is established in advance and based on reported health care charges from which a predetermined per diem rate is determined?

Accepted Answer

A prospective cost-based rate is established in advance and is based on reported health care charges to determine a predetermined per diem rate.

Question 14

Home Assessment Validation and Entry (HAVEN) __________ software is then used to collect OASIS assessment data for transmission to state databases.

Accepted Answer

HAVEN software is used for data entry to collect OASIS assessment data for transmission to state databases.

Question 15

The end-stage renal disease (ESRD) composite payment rate system is __________ adjusted to provide a mechanism to account for differences in patients' utilization of health care resources.

Accepted Answer

The ESRD composite payment rate system is case-mix adjusted to account for differences in patients' health conditions and their utilization of healthcare resources, ensuring fair and adequate reimbursement.

Question 16

HIPPS codes are determined after home health care patient assessments using the __________ are completed.

Accepted Answer

HIPPS codes are determined after home health care patient assessments using the OASIS (Outcomes and Assessment Information Set).

Question 17

Which is a facility's measure of the types of patients treated and reflects patient utilization of varying levels of health care resources?

Accepted Answer

Case mix is a measure that reflects the types of patients treated in a facility and their utilization of varying levels of health care resources.

Question 18

An ambulatory surgical center (ASC) is a state-licensed, Medicare-certified supplier (not provider) of surgical health care services that must __________ on Medicare claims.

Accepted Answer

ASCs must accept assignment on Medicare claims, meaning they agree to accept the Medicare-approved amount as full payment for covered services.

Question 19

Which type of software is used to determine the appropriate HHRG after OASIS data is input on each patient (to measure the outcome of all adult patients receiving home health services)?

Accepted Answer

A grouper software is used to assign Home Health Resource Groups (HHRG) based on the OASIS data input for patients receiving home health services.

Question 20

DRG reimbursement rates are recalculated according to a(n) __________ adjustment, which results in increased Medicare payments for hospitals that treat a high percentage of low-income patients.

Accepted Answer

Disproportionate Share Hospital (DSH) adjustment increases Medicare payments to hospitals that serve a high percentage of low-income patients.

Quiz 9: Cms Reimbursement Methodologies