Ch. 2 Reimbursement Processes and Tools

Question 1

What kind of department is the HIM Department

Answer 1

a service department

Question 2

responsibility of Health Information Management

Answer 2

ensure claims for services are accurate and complete

Question 3

Where are charges posted?

Answer 3

In accounts receivable (A/R)

Question 4

what happens when charges are captured on the claims?

Answer 4

bills are dropped to A/R (moves to accounting department)

Question 5

Accounts receivable

Answer 5

all the money that is owed to the business that they have not gotten yet.
charges posted = A/R goes up
payment recieved = A/R goes down

Question 6

in A/R when is revenue is recorded?

Answer 6

when it is earned
after service is done but before they get money

Question 7

in A/R when is cash recorded?

Answer 7

when they recieve the payment

Question 8

discharged not final billed report (DNFB)

Answer 8

include all patients disharged from facility for whom billing process is not complete.

Question 9

bill- hold period

Answer 9

3 days for bills to be finalized before it considered DNFB.
awaiting late charges, diagnosis or procedure codes, or other required info

Question 10

why do coders work with physicians and CDI specialists

Answer 10

to avoid coding discrepancies

Question 11

what depatment edits bills for missing or inaccurate links?

Answer 11

billing departments

Question 12

Accounts Receivable Days

Answer 12

average # of days between discharge date & receipt of payment for service rendered
-measure success of revenue cycle

Question 13

Medicare

Answer 13

65+ yrs or under 65 with disability
any age/person with instinct renal disease

Question 14

Medicare A covers

Answer 14

hospital services

Question 15

Medicare B covers

Answer 15

outpatient services
durable equipment like wheelchairs
monthly premium

Question 16

Medicare C covers

Answer 16

advantage plans like eye, dental care
pt pays monthly premium

Question 17

Medicare D covers

Answer 17

prescriptions
pay deductable, copay

Question 18

Medicaid

Answer 18

low income adults, children, pregnant women, elderly, people with disabilities

Question 19

Children Health Insurance Program (CHIP)

Answer 19

for uninsured children/family that make too much for medicaid but not enough for private insurance

Question 20

Tricare

Answer 20

active or retired military members & families or from members that was killed

Question 21

CHAMPVA

Answer 21

for veterns not eligible for Tricare or spouse/kids from one that was disabled from services

Question 22

Indian health services

Answer 22

medical and public health service for federal recognized native american nations and alaska natives

Question 23

Workers Compensation

Answer 23

medical benefit to people with work related injury or illness

Question 24

Commercial Insurance

Answer 24

Humana
blue cross
aetna

Question 25

Fee-for-Service

Answer 25

also known as indemnity health insurance
provider is paid after service provided/billed
issue: incentivizes quantity as doctor get paid per patient/service
-paid retrospectively

Question 26

Managed Care Organizations (MCOs)

Answer 26

plans include provider networks, provider oversight, prescription drug tier, quality of care, resource monitoring

Question 27

MCO was designed to ?

Answer 27

manage costs for provider and payer without sacraficing quality care

Question 28

Preferred Provider Organization (PPO)

Answer 28

most common
large network of covered doctors/hospitals in network
patient pays less to see those “in network”

Question 29

Health Maintenance Organization (HMO)

Answer 29

smaller selection of in network option to choose from
monthly premuims lower than PPO
patient required to have PCP
emphasis on prevantive care

Question 30

Point of Service Plan (POS)

Answer 30

smaller network
low cost
required to have PCP

Question 31

Prospective Payment System is

Answer 31

based on predetermined, fixed amount based on classification system for that service
used by CMS for medicare

Question 32

Medicare Physician Fee Schedule

Answer 32

predetermined rate
reimburse provider for services covered by medicare B
RVUs

Question 33

Relative Value Units (RVUs)

Answer 33

payment component that measure value of service compared to others
- physician work
- practice expense
- malpractice expense
uses Geographic Adjustment Factor (GAF)

Question 34

Participating Providers (PAR)

Answer 34

doctors agreed to accept medicare,, reveive direct payment of all claims
medicare pay 80%, patient responsible for 20%

Question 35

Non participating Provider (nonPAR)

Answer 35

have not agreed to accept assignment of claims
may accept on claim by claim basis
limiting charge, reduction of 5% allowable charge

Question 36

Goal of Accountable Care Organization (ACOs)

Answer 36

improve quality of patient care, lower cost, enable all cities to have access to affordable care
anyone without health insurace qualifies for ACO

Question 37

Characteristics of ACOs

Answer 37

-not a health insurance plan
-manage patient across continuum of care
-prospectively plan budget and resource needs
-big enough to support comprehensive,valid, reliable measurement of performance

Question 38

Preadmission Review

Answer 38

prior authorization or pre certification required by some insurance plans before patient admitted for non emergency procedure/service

Question 39

Utilization Review

Answer 39

preadmission, looking for medical necessity before patient admitted, entire time in hospital (concurrent), after discharge (retrospectively)

Question 40

Case Management

Answer 40

group of people like social workers , to plan out and make sure resources being used properly
improve quality care while reducing cost

Question 41

Encoder software

Answer 41

uses algorithim that mimic a tree
can not rely on its own as it can lead to wrong conclusion

Question 42

Computer Assisted Coding (CAC)

Answer 42

incorporate AI into coding
cannot replace human coding as it is a lot less logical

Question 43

CAC software - Natural language processing (NLP)

Answer 43

read electronic health record, pull out keyword and phrases in order to predict what code to use

Question 44

logic based and knowledge based systems

Answer 44

based on rules - logic based software
uses keyword search tools- knowlege based

Question 45

deep learning systems

Answer 45

act as a coding assistant to the medical coder
learn and adapt by looking at patterns

Question 46

Benefits and features of CAC application

Answer 46

-coding professional learn ICD-10 more quickly with repetition
-accuracy can be studied retrospectively
-increased efficiency
-return on investment achieved