Ch 17: Review Test

Question 1

Payment to the insured (or his or her provider) for a covered expense or loss experienced by or on behalf of the insert is referred to as what?

Answer 1

Reimbursement

Question 2

A system of payment whereby the provider charges a specific fee for each service rendered and is paid that fee by the patient’s insurance carrier is called ____

Answer 2

Fee-for-service

Question 3

Medicare’s system for reimbursing Part A inpatient hospital costs is called what?

Answer 3

Prospective payment system (PPS)

Question 4

The amount of payment in the PPS (prospective payment system) is determined by the assigned ____

Answer 4

Diagnosis-related group (DRG)

Question 5

A common method of paying physicians in health maintenance organizations is ____

Answer 5

Capitation

Question 6

PPS (prospective payment system) for acute hospital care for Medicare patients was mandated by what?

Answer 6

Social Security Amendments of 1983

Question 7

What is the method of determining Medicare’s reimbursement for services based on establishing a standard unit value for medical and surgical procedures?

Answer 7

RVS (relative value scale)

Question 8

Patients whose hospital stays are either considerably longer or considerably shorter than average are referred to as what?

Answer 8

Cost outliers

Question 9

In the ____, payments for services are determined by the resource costs needed to provide them rather than actual charges

Answer 9

Resource-based relative value scale (RBRVS)

Question 10

The key piece of information in determining the DRG (diagnosis-related group) classification is the patient’s ____

Answer 10

Principal diagnosis

Question 11

Also taken into consideration in determining the DRG (diagnosis-related group) is the patient’s ____ and any additional operations and procedures done when in the hospital

Answer 11

Principal procedure

Question 12

A computer software program that takes the coded information and identifies the patient’s DRG (diagnosis-related group) category is a ____

Answer 12

DRG grouper

Question 13

A service classification system designed to explain the amount and type of resources used in an outpatient encounter is ____

Answer 13

APCs (Ambulatory Payment Classification)

Question 14

Ambulatory payment classifications are made up of the coding and classifications of services provided to the patient based on the ____

Answer 14

• ICD coding system

- HCPCS Level 2 coding system

Question 15

The basic idea of the resource utilization groups (RUGs) is to calculate payments according to severity and level of care in ____

Answer 15

Skilled nursing facilities

Question 16

A factor used by Medicare to adjust for variance in operating costs of medical practices located in different parts of the United States is the ____

Answer 16

GPCI (geographic practice cost index)

Question 17

Calculating DRG (diagnosis-related group) payments involves a formula in which the DRG weight is multiplied by a ____, a figure representing the average cost per case for all Medicare cases during the year

Answer 17

Standardized amount

Question 18

Under Medicare’s PPS (prospective payment system), long-term care hospitals (LTCHs) generally treat patients who require hospital-level care for an average of ____ days

Answer 18

25 days

Question 19

An adjustment to the federal payment rate for LTCH (long-term care hospital) stays that are considerably shorter than the average length of stay for an LTC-DRG is called a(n) ____

Answer 19

Short-stay outlier

Question 20

Under the Home Health PPS (prospective payment system), an adjustment for the health condition and service needs of the beneficiary is referred to as the ____

Answer 20

Case mix adjustment

Question 21

An organization typically composed of physicians and other healthcare professionals who are paid by the federal government to evaluate the services provided by other practitioners and to monitor the quality of patient care is called what?

Answer 21

PRO (peer review organization)

Question 22

If an agreement does not exist between the provider and the insurance carrier to accept the payer’s allowed amount as payment in full, the provider can bill the patient for the outstanding amount, which is referred to as _____

Answer 22

Balance billing

Question 23

Under PPS (prospective payment system), reimbursements for each hospital are adjusted for differences in what three categories?

Answer 23

• Area wages
• Teaching activity
• Care to the poor

Question 24

When the healthcare provider has assigned an agreement with a third party not to bill for any charges remaining after all required payments have been made, it is called ____

Answer 24

A contractual write-off