Ch 17: Review Test Flashcards
Reimbursement Procedures: Getting Paid
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?
Reimbursement
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 ____
Fee-for-service
Medicare’s system for reimbursing Part A inpatient hospital costs is called what?
Prospective payment system (PPS)
The amount of payment in the PPS (prospective payment system) is determined by the assigned ____
Diagnosis-related group (DRG)
A common method of paying physicians in health maintenance organizations is ____
Capitation
PPS (prospective payment system) for acute hospital care for Medicare patients was mandated by what?
Social Security Amendments of 1983
What is the method of determining Medicare’s reimbursement for services based on establishing a standard unit value for medical and surgical procedures?
RVS (relative value scale)
Patients whose hospital stays are either considerably longer or considerably shorter than average are referred to as what?
Cost outliers
In the ____, payments for services are determined by the resource costs needed to provide them rather than actual charges
Resource-based relative value scale (RBRVS)
The key piece of information in determining the DRG (diagnosis-related group) classification is the patient’s ____
Principal diagnosis
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
Principal procedure
A computer software program that takes the coded information and identifies the patient’s DRG (diagnosis-related group) category is a ____
DRG grouper
A service classification system designed to explain the amount and type of resources used in an outpatient encounter is ____
APCs (Ambulatory Payment Classification)
Ambulatory payment classifications are made up of the coding and classifications of services provided to the patient based on the ____
- ICD coding system
- HCPCS Level 2 coding system
The basic idea of the resource utilization groups (RUGs) is to calculate payments according to severity and level of care in ____
Skilled nursing facilities
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 ____
GPCI (geographic practice cost index)
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
Standardized amount
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
25 days
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) ____
Short-stay outlier
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 ____
Case mix adjustment
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?
PRO (peer review organization)
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 _____
Balance billing
Under PPS (prospective payment system), reimbursements for each hospital are adjusted for differences in what three categories?
- Area wages
- Teaching activity
- Care to the poor
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 ____
A contractual write-off
