Healthcare Reb. Final
“Under Medicare prospectie payment system for skilled nurising facilities, which healthcare service is excluded from the consolidated payment?”
What tool does CMS require that skilled nursing facilities use to collect and to report clinical data on residents?
Minimum Data Set (MDS)
What tool does the SNF PPS use to annually adjust the base rate for differences in local markets?
Market Basket Index
“In medicares prospective payment system for skilled nursing facilities, what classification is used to adjust for case mix?”
“In Medicares prospective payment system for skilled nursing facilities, which data set determines a residents classification into a resource utilization group?”
“CMS analysts divide admission to skilled nursing facilities into upper and lower categories. To which of the following categores does the “”presumption of coverage”” apply?”
“Rehabilitation Plus Extensive, Rhabilitaion”
What tool does CMS regire that long-term care hospitals use to collect and to report clinical data on patients?
Long-term care hospitals Coninuity Assessment and Record Evaluation (CARE) data set
“In Medicares prospective payment system for long-term care hospitals, what classification is used to adjust for case mix?”
A patient with which condition is an appropriate candiate for an LTCH?
“Under Medicares prospective payment system for long-term care hospitals, all of the following elements used to group patients into a MS-LTC-DRG except::”
Qualifying diagnosis at acute inpatient hospital prior to admission to LTCH
What cost-sharing applies to a Medicare beneficiary who did NOT have an immediately proceding admission at an acute care hospital AND resides in a LTCH for 90 days?
“Inpatient deductible for the 90 day benefit period, Daily coinsurance payment for days 61-90.”
“In most situations, for a facility to be defined as an LTCH, the lengths of stay of its Medicare patient must be at least how long?”
“True or False? Even though Medicare-severity Long-term care diagnosis related groups (MS-LTC-DRGs) are based on the same general factors as the acute-care MS-DRGs for the IPPS, MS-LTC-DRGS differ from acute-care MS-DRGs because MS-LTC-DRGs have different relative weights and use quintiles for low volumes.”
What converts the MS-LTC-DRG into an unadjusted payment amount?
Standard federal rate
“In medicares prospective payment system for impatient rehabilitation facilities , what classification is used to adjust for case mix?”
All of the following types of diagnosis are used in the IRF PPS except:
All of the following elements are part of the IRF PPS except:
Major diagnostic category
“What is the term used in a rehabilitation facility to mean “”a patients ability to perform activities of daily livings””?”
“What tool, that drives payment, is used to collect information about Medicare patients in the IRF PPS?”
Inpatient rehabilitation facility patient assesssment instrument (IRF PAI)
“True or False? For inpatient rehabilitation facility patients, codes on the IRF PAI should follow the UHDDS and the UB-04 guidelines?”
Coders in inpatient rehabilitation facilities (IRFs) use ICD codes for all the following purposes except:
Reason for admission to the IRF
“In IRFs, all tof the following reasons are purposes for codes except:”
Documenting patients fuctional statuses
“In an IRF, on what tool is are patients abilites to perform activities of daily living recorded?”
Fuctional Independence Measure (FIM) Assessment
True or False? Ifacilities transmit IRF PAIs to the Centers for Medicare and Medicaid Services using CMS free IRVEN software.
What tool does CMS require that home healht agencies use to collect and to report clinical data on patients?
Outcome Asessment and Information Set (OASIS)
Which discounted fee-for-service health care payment method does Medicare use to reimburse physicians?
All of the following methods are types of episode-of-care reimbursement except:
“In the health care industry, what is the term for receiving compensation for health care services that were previously provided?”
Payers that use per-diem payment rates reimburse the provider a fixed rate for each day a covered member is hospitalized.
Where and when did health insurance become established in the US?
There are 3 parties in healthcare reimbursement. Who is the third party?
“In the heatlh care industry, what is another term for “”fee””?”
“The bill that the pathologist office submitted for a laboratory test was $54.00. In its payment notice (remittance advice), the health care plan lists its payment for the laboratory test as $28.-00. What does the amount of $54.00 represent?”
What is the purpose of managed care?
“To reduce the cost of healthcare services, To improve the quality of care for patients”
The federal government funds significant portions of which groups healthcare?
“Seniors, People with disabilities, endstage renal disease, low-income persons on state medicaid, Active duty and retired military personnel and their families, Native Americans”
Which national model for the delivery of health care services is financed by general revenue funds from taxes?
National Health Service (Beveridge) model
“Which of the following phrases mean “”per head”””
Which type of reimbursement methodology does the health insurance company have the greatest degree of risk?
“Which type of reimbursement methodology is associated with the abbreviation “”PMPM”””
Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to calculate the group’s premiums?
To assure that the pool is large enough to pay losses of the entire group
“In the heatlhcare sector, what does UCR stand for?”
“Usual, Customary and Reasonable”
Which of the following payment methods are global?
“Block grants, Surgical Packages, Bundling”
There are 3 parties in healthcare reimbursement. Who is the second party?
Provider of services
“The constant trend of increased national spending on healthcare is a concern beause as spending on health care increase, the money available for other sectors of the economy decrease”
“In the US, What is healthcare insurance?”
Reduction of a persons or a groups exposure to risk for unknown healthcare costs by the assumption of that risk by an entity
“In the accounting system of the physicians office, the account is categorized as “”self-pay””. How should the insurance analyst interpret this category?”
The guarantor will pay the entire bill
Which statement describes the per diem payment method?
Fixed rate for each day a covered member is hospitalized
To which of the following factors is health insurance status most closely linked?
In which type of reimbursement methodology do health care insurance companies determine payment to providers before the services have been delivered?
There are three parties in healthcare reimbursement. Who is the first party?
Patient or quarantor
Which type of RAC review combines data analysis and submission of medical records to the RAC?
Which of the following is not a common cause of improper payments?
Implementation of a documentation improvement program
The coding system that is used primarily for reporting diagnoses for hospital inpatient is known as:
Recovery audit Contractors are different from other improper payment review contractors because:
RACs are reimbursed on a contingency-based system
The RAC appeals process has ___________levels
Which of the following is an example of fraud?
Billing for services not furnished as represented on the claim
The polocies and procedures section of a coding compliance plan should include:
“Upcoding, Coding medical records without complete documentation,m Correct use of encoding software”
Which of the follwing entities does not perform improper payment reviews for CMS?
None of the above
Which of the following coding systems was created for reporting procedures and services performed by physicians in clinical practice?
Which of the following is the correct format for HCPCS Level 11 codes?
“In the healthcare industry, all of the following benefits terms mean the amount during a timeframe beyond which all covered healthcare services for an insured or dependent are paid 100% by the insurance plan except?”
“Which of the following entities is also known as a “”group plan””?”
Employer-based healthcare insurance plan
Which of the following characteristics is representative of commericial healthcare insurance?
For-profit in the private sector
All of the following specifications are types of limitations on healthcare polocies except?
Which type of healthcare insurance policy provides benefits to a resident requiring nursing home care and services?
Long term or extended care insurance
All the following are cost-sharing provisions except?
which type of prescription drug is the LEAST costly for insureds using their drug benefit?
“All of the following phenomena are considered “”life events”” except: “
All of the following data elements are on a RA except:
“In the healthcare industry, what is the term for the written report that insureres use to notify insureds about the extent of payments made on a claim?”
Explanation of Benefits
“In the healthcare sector, when a patients healthcare services are covered under a voluntary healthcare insurance plan, the person who pays the remiander of the healthcare bill, after the heatlhcare insurance company has paid, is called the guarantor”
“Both parents of a dependent child had employer based group health insurance. Per the “”birthday rule”” the primary payer for the dependent child is the insurance of the parent whose birthday comes first in the calender year”
What healthcare organization is one of the most influential in the healthcare sector because it insures nearly one in three americans?
Which type of healthcare insurance policy provide benefits to pay for Medicare deductibles and coinsurance?
Out of pocket costs for subscribers and patients are decreasing
What is the term for the contract between the healthcare insurance company and the individual or group for whom the company is assuming the risk?
“In the healthcare sector, what is the term for the fixed dollar amount that the guarantor pays?”
which type of health insurance policy provides benefits to an insured who is blinded as the result of an accident?
accidental dealth and dismemberment insurance
Which of the following characteristics is the greates advantage of group healthcare insurance?
Greater benfits for lower premiums
Which type of health care insurance policy provides benefits to a homeowner who requires an 8 month recuperation after a fall down her basement stairs?
disability income protection insurance
“What is the term for a group of individual entities, sushc as individual persons, employers, or associations, whose healthcare costs are combined for evaluating financial history and estimating future costs?”
Which type of healthcare insurance policy offers the widest ranging coverage but requires the insured to pay coinsurance until the maximun out-of-pocket costs are met?
“All of the following phenomena are typically exlusions found in insurance plan riders, except?”
emergency care under the prudent lyperson standard
Which government-sponsored program provides coverage for the dependents of active members of the armed forces?
which of the following is/are true of CHIP?
“It is a federal/state program, It varies from state to state”
Which of the following statements about Veterans Health Administration is False?
Basic eligibility includes all veterans who served in active military service regardless of the separtation condition
Medicare Part C is a _________ option known as Medicare Advantage
Which government sponsored program is desinged to help needy families achieve self sufficiency?
Temporary Assistance for Needy Families Program (TANF)
In states where there is not a mandated fund for workers compensation which of the following is an option for employers?
“Purchase workers compensation insurance from a private carrier, Provide workers compensation self-insurance coverage”
All fo the following are ture of state medicaid programs except:
Services offered to beneficiaries are the same in each state
Which part of the medicare program does not include a cost sharing provision?
all parts of medicare include a cost sharing provision
The civilian health and medical program of the Department of Veterans affairs (CHAMPVA) is available for:
“Spouse or widower of a veteran meeting specific criteria, Children of a veteran meeting specific criteria.”
For what reasons do MCOs survey their members for feedback?
All the above
For what type of care should the physician practice manager expect to work with a case manager?
Alll of the following functions are way that MCOs work toward their goal of quality patient care EXCEPT:
Applying PMPM payment system
Which of the following activites do MCOs use as financial incentives to control costs?
All the above
Episode of care management includes capitated reimbursement and global payment
“What is the term that means evaluating, for a healthcare service, the appropirateness of its setting and its level of service?”
Which type of MCO allows patients to choose how they will receive services at the time that the patients need the service
“A patient who was a Medicaid recipient, asked about the types of ifnancial incentives that the MCO used. What should the MCOs administrator do?”
release summaries of the financial incentives
Access to mental or behavioral health or medial specialists is through referral. What is the term for the individual who makes the referral?
Which of these are NOT an element of prescription management?
links to electronic banking
All of the following types of organizations represents ways of integrating health organizations EXCEPT:
solo physician practice
All of the following activites are steps in medical necessity and utilization review EXCEPT:
The patient belongs to a managed care plan. The patient wants to make an appointment with an out-of-network. What should the patient expect?
the paitents out of pocket costs will be increased
Who are dual eligibles?
individuals who are eligible Medicare and Medicaid
Disease management is closely associated with coordination of are tools of MCOs because efforts of multiple providers must be synchronized in disease management
“What term means a network of organizations that directly provides or arranges to provide a coordinated continuum of services to a defined population and takes accountability for the cost, quality and outcomes of care?”
integrated delivery system
Evidence based clinical guidelines orignate from all the following sources EXCEPT:
physicians personal clinical experiences
Which of the following types of care represent healthcare services delivered by MCOs?
all the above
All of the following actions reflect the roles of PCPs in MCOs EXCEPT:
refer patients to colleagues for immunizations and other general care
What was the purpose of the Health Maintenance Act of 1973?
to encourage the delivery of affordable quality healthcare
What is the term for an MCO that serves Medicare beneficiaries?
In which type of HMO are the physicians employees?
“All of the following types of services or populations are common examples of “”carve outs”” EXCEPT:”
immunizations and well-baby care
What is the average of the sum of the relative weights of all patients treated during a specified time period?
case mix index
Which of the following is not a facility-level adjustment under the IPF PPS?
Which of the follwing concepts is a guiding principle of prospective payment?
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””?”
“facilities costs related to payroll, benefits, and professional fees”
What is the first step in determinings an MS-DRG assingment for an encounter?
Mart smith was admitted to IPF hospital A on April 1. She is discharged on April 5. Mary smith is readmitted to IPF hospital B on April 7 and continues the hospital stay until April 10. What lengh of stay adjustment day should be used to calculate the payment for the first day payment for IPF Hospital B?
“Within the IPF PPS, which of the following statements is true?”
the cost for psychiatric cases decreases as the length of stay increases
Which reimbursement methodology is used in the Inpatient Psychiatric Facility PPS?
per diem rate
What is the general term for software that assins inpatient DRGs?
“In the IPPS, what is the term for each hopsitals unique standardized amount based on its costs per Medicare discharge?”
base payment rate
When comparing Medicares IPPS and IPF PPS which of the following statements is false?
Both PPS utilize a case rate reimbursement methodology
The MS-DRG payment includes reimbursement for all the following inpatient services EXCEPT:
physican hospital visit
“In which governement publication are the details about the various PPS introduced, commented on and finalized?”
What is the correct formula for wage index adjustment?
(payment rate*labor portion*WI) + (payment rate*non-labor portion)
What medicare contractor reimburses acute care hospitals on behalf of Medicare?
Medicare administrative contractor (MAC)
What is the rate year (RY) for IPPS?
What is NOT a patient level adjustment used in the IPF PPS?
full serivice emergency department
Which piece of legislation called for the first hospital inpatient PPS? This piece of legislation also allowed some hospitals settings to retain their cost based payment system?
(TEFRA) Tax Equity and Fiscal Responisbility Act
A medicare paient was discharged from one acute IPPS and admistted to another acute IPPS hospital on the same day. How will the two acute IPPS hospitals be reimbursed?
the first hospital receives a per-diem payment rerived from the potential MS-DRG and the second hospital receives the full MS-DRG
Under IPF PPS which states are included in the cost of living adjustment (COLA)?
Hawaii and Alaska
“In MS-DRGs, for what is the case-mix index a proxy?”
consumption of resources
Which IPPS provision is provided to facilities that experience a financial hardship because they provide treatment to patients who are unable to pay for the services?
disproportionate share hospital
Define Principal diagnosis
“the reason “”established after study to be responsible for occasioning the admission of the patient to the hospital for care”” “
Under ESRD PPS how many treatments does a facility need to provide within a year to qualify for low volume facility adjustment?
“less than 4,000”
“Under the hospice payment system, which category of daily rate is the LOWEST?”
routine home care
“Under OPPS, outpatient services that are similar both clinically and in use of resources are assinged to separate groups called?”
“Medicare-certified ASCs must accept assignment, meaning:”
An ASCs must accept Medicare pyament as payment in full
Which researcher is associated with Medicares RBRVS payment system?
“In the APC system, an outlier payment is paid when which of the following occurs?”
the cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount
What is the maximum number of APCs that may be assigned per encounter?
“In Medicare’s RBRVS payment system, which site of care is considered a facility?”
“Under the Ambulance Fee Schedule, What is used to determine the level of service for ground transport?”
EMS provider skill set used during the transport
What is the labor percentage utilized in the Ambulance Fee Schedule wage index adjustment?
Which federal law authorized payemtn for the Medicare Hospice benefit?
“In Medicares RBRVS system , what is the term for the national dollar amount that is annually designated to convert relative value units into dollars?”
“In Medicares RBRVS system , which factor adjusts payment to physicians and health professionals for price differences among various parts of the country?”
geographic practice cost index
Which APC component is a measure of the resource intensity of a particular procedure or service?
Under the ASC PPS medicare payemtn equals ________ percent and the beneficiary copayment equals _______of the total reimbursement of services provided.
“Which element of the ralative unit accounts for the operational costs of delivering healthcare services, such as rent, wages of technical personnel, and supplies and equipment?”
Which university is associated with the development of Medicares RBRVS payment system?
“What is the term for an urban, nonprofit, patient-governed, and community-directed health care entities receiving federal grant funding under Section 330?”
federally-qualified health centers
“In Medicares resource based relative value scale payment system, to which type of code has a relative value unit been assigned?”
CPT (healthcare common procedure coding system)
What is not a separate payment service under the ASC PPS?
For which clinician is Medicare’s RBRVS payment system modified by a formula that includes base units and time?
Which type of service includes an APC per diem rate that includes payments for all services provided in a single day of service under OPPS?
What payment methodology is utilized in the ESRD PPS?
case rate per treatment session
“When a patient is pronounced dead prior to an ambulance being called, which of the following provisions is followed under the Ambulance Fee Schedule?”
no Payment is made to the ambulance supplier/provider
Which type of APC is used to increase bundling and move toward an episode of care based payment system?
“In Medicares prospective payment system for home health services, what classification is used to adjust for case mix?”
“Within a 60 day episode of care, what home health care services are consolidated into a single payment to home health agencies?”
“All therapy, Skilled nurising visits, Medical social services”
True or False? DME is EXCLUDED from the HHPPS
“In Medicares prospective payment system for home health services, what software is used to electronically submit data?”
Home Assistance Validation and Entry (HAVEN)
All of the following dimensions are used to calculate an HHRG except:
Type of clinician providing service
“True or False? HIPPS codes are “”itelligent”” because the number or letter in each position provides information. “
“In the HHPPS, what does the abbreviation LUPA Stand for?”
Low-utilization payment adjustment
“In Medicares PPS for home health services, under the LUPA provision, what is the maximum number of visits for which an agency may receive reimbursement??”
for what variations in resources consumption does Medicare PPS for home health services account?
# of therapy visits by therapist
“Under medicares PPS for post acute care, which component is directly adjusted by the local wage index?”
Which of Medicares PPS for postacute care is per diem?
Skilled nursing facility PPS
“Value Based Purchasing and Pay for Performance and system typically link all the following components except:Quality, Setting of care, Performance, Payment”
Setting of Care
“What is the term that means making available to the public, in a reliable and understandable manner, information on a healthcare organizations quality, efficiency, and consumer experience with care, which includes price and quality data, so as to influence the behavior of patients, providers, payers, and others to achieve better outcomes?”
When did P4P systems first emerge in the healthcare sector?
What reports drove the establishment of value-based purchasing and P4P and system in the healthcare sector?
“Crossing the Quality Chasm, Rewarding Provider Performance: Aligning Incentives in medicare”
“Since the 2000s, what terms characterize the rate of establishing value based purchasing and P4P and systems in the healthcare sector?”
True or False? P4P and VBP are phenomena unique to the US healthcare delivery system.
What are the two major categories of P4P models?
Reward based models and penalty based models
“What is the term for a model of primary care that seeks to meet the heatlhcare needs of patients and to improve patient and staff experiences, outcomes, safety, and system efficiency?”
Patient-centered medical home
“In value based purchasing and P4P systems, what is the term for the process of identifying the clinician who provided the care, is responsible for the cares quality, and is accountable for the cares cost?”
“In VBP and P4P systems, which incentive is financial?”
Higher fee schedule
“In the healthcare sector, why are incremental implementations of VBP and P4P systems preferable to full-scale implementations?”
Sponsors can evaluate policies and procedures
What targets should be the focus of P4P and VBP systems?
“Most significant problems in terms of quality or cost, Proportion of populations covered by the service or provider, Availabitlity of valid and reliable performance measures”
“In VBP and P4P systems, which attribute should adopted performance measures characterize?”
Which piece of legislation initaiated the Reporting of Hosptial Quality Data for Annual Payment Update (RHQDAPU) program?
Medicare Modernization Act
Which component of Medicares VBP plan monitors the action of reporting data in the proper format within the given timeframe?
Pay for Reporting
What is the payment reduction for hospital and faclities that fail to successfully meet requirements of Medicares Pay for Reporting Programs?
Within the Medicare VBP framework improving efficiency means
Reducing the cost to treat each beneficiary
“All of the following elements are found in a charge description master, except: “
What is the definition of revenue cycle management?
“Coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.”
“The term “”soft coding”” refers to: “
CPT codes that are coded by coders
“In heatlhcare setting, the record of the case the facility will receive for the services it has provided is known as?”
The remittance advice is provided to which party?
Most facilites begin counting days in accounts receivable at which of the following times
The date the bill drops
The amount of money owed a healthcare facility when claims ar pending is called:
Dollars in accounts receivable
The dollar amount the facility actually bills for the services its provideds is known as:
The difference between what is charged and what is paid is known as:
“What is the name of the notice sent after the provider files a claim that details amounts billed by the providers, amounts approved by the payer, how much the payer paid, and what the patient must pay?”
EOB (Explanation of Benefits)
“Which is a characteristic of the “”old”” RCM approach?”
Which entity is responsible for processing Part A claims and hospital based Part B claims for intitutional services on behalf of medicare?
Medicare administrative contractor (MAC)
“In a typical acute-care setting, Admitting is located in which revenue cycle area?”
“In a typical acute care setting, Aging of Accounts reports are monitored in which revune cycle area?”
Charge Entry is located in which revenue cycle area?
Which revenue cycle area uses an internal auditing system (scrubber) to ensure that error free claims (clean claims) are submitted to third-party payers?
What CDM data element is nationally recognized?
Which of the following compliance documents services as day to day operating instructions for administering CMS programs
Medicare Claims Processing Manual
scrubbers are used by hospitals to identify which of the following errors that can cause claims rejections or denials?
“Incompatible dates of service, Nonspecific or inaccurate diagnosis and procedure codes, Lack of medical necessity, (all the above)”
Which type of compliance guidance is used by Medicare to communicate policies and procedures for the specific PPS manuals?
CMS programs Transmittals
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