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Medical Billing and Health Insurance > Discuss Other Various Payment Systems > Flashcards

Discuss Other Various Payment Systems Flashcards

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USMLE® Step 1 flashcards
1
Q

When involving inpatient scenarios in which the prospective payment system and DRGs are used, physicians’ offices use the ____________ system?

A

Resource-based relative value scale (RBRVS)

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2
Q

What is the facility fee?

A

The amount reimbursed to the hospital when the patient receives hospital care.

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3
Q

Do physicians split the facility fee with hospitals or?

A

No, they receive a separate amount for the services provided.

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4
Q

What is service fees?

A

Medical consultation, surgery, etc. (the service the physicians give the patient).

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5
Q

What is the RBRVS system based on?

A

The ‘relative value of services’ based on a formula.

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6
Q

What is the formula that RBRVS systems are based on?

A
  • Amount of work a physician does to treat a patient (RVUw, or relative value unit [work]

-Expenses associated with the treatment (RVUpe, or relative value units [practice expenses])

-Professional liability assessed for that treatment (RVUm, or relative value units [malpractice costs]

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7
Q

What is the RVUw?

A

Relative value units [work], amount of work a physician does to treat a patient

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8
Q

What is RVUpe?

A

Relative value units [practice expenses], expenses associated with treatment

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9
Q

What is RVUm?

A

Relative value units [malpractice costs], professional liability insurance assessed for that insurance.

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10
Q

Where does the CMS publish the RVUs?

A

As part of the Medicare fee schedule (MFS) each year within the publication called the Federal Register. (helps to understand what’s reimbursed under medicare)

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11
Q

What is the RBRVS system used for?

A

To reimburse physicians treating patients under Medicare Part B. was developed to cover Medicare patients but now is used by other payers

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12
Q

What is the RBRVS system based on?

A

Standard service with a relative value (Standard relative value is 1.00),

CPT/HCPCS system is used to code these. (as opposed to ICD-10-CM for inpatients)

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13
Q

What is the conversion factor?

A

An assignment by CMS each year that helps convert RVUs into actual payments.

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14
Q

What is a skilled nursing facility (SNF)?

A

A facility designed for treating Medicare-elgible patients. Usually part of a nursing facility, but could be part of a hosital.

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15
Q

When is SNF care needed?

A

Generally only a short period of time after a hospitalization.

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16
Q

What does treatment in SNFs include?

A

24-hour nursing coverage, physical therapy, occupational therapy, and speech therapy.

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17
Q

When is a person no longer qualified for SNF care?

A

When a person doesn’t require continuous medical evaluation.

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18
Q

What is per diem?

A

Reimbursement based ons ervice by the day, (Daily).

19
Q

What is reasonable cost?

A

Regular cost to treat a patient with that disease, illness, or injury.

20
Q

What does IPPS (Inpatient propsective payment system) use for reimbursement?

A

MS-DRGs

21
Q

What do physician offices use for reimbursement?

A

RBRVS systems.

22
Q

What does the SNF PPS use for reimbursement?

A

Resource utilization groups (RUGs) .

23
Q

How does the RUG system work?

A

SNF patient (or resident) assessment data is used to then assign one of the RUGs for reimbursement calculation reported by HCPCS. (Healthcare Common Procedure Coding System : used to track information and reimbursement procedures).

24
Q

What is one of the ways that long-term care facilities collect and transmit data?

A

RAVEN: Resident Assessment Validation and Entry.

25
Q

What is RAVEN?

A

Computerized system developed by the CMS that helps to import and export the data in specific format required by the CMS.

Long-term Care.

26
Q

What are historical costs?

A

Costs based on previous costs of treatment —usually 80 percent of charges.

27
Q

What is OPPS?

A

Outpatient prospective payment system.

28
Q

What does OPPS do?

A

Pays hospital-specific, predetermined rates for outpatient services based on national payment rates weighted by factors such as location of the healthcare facility.

29
Q

What is the OPPS based on?

A

A classification system called APC (ambulatory payment classification) groups.

30
Q

How do APCs work?

A

Similar to inpatient DRG or MS-DRG. Groupings of each APC are based on services that are clinically similar in relation to resources used, and payment rates are established for specific APCs. They are also assigned relative weights for payment calculations.

Each reimbursable HCPCS code is assigned to an APC for reimbursement purposes. Unlike inpatient records that are assigned one DRG or MS-DRG, outpatient records can be assigned multiple APCs based on services provided and payment is calculated based on the sum of each of the services provided.

31
Q

What is a home health agency (HHA)?

A

Certified facility approved by a health plan to provide services under a contract.

32
Q

What is OASIS?

A

Outcome and Assessment Information Set.

A data set used in home healthcare for patient assessments to help monitor and improve the outcomes, or the end results, of care. Home healthcare outcomes measure the effectiveness of home healthcare services provided.

33
Q

What is OASIS important for?

A

-Patient Assessment and care planning

-Case-mix and statistical reports

-Performance improvement.

34
Q

What is HAVEN?

A

Home Assessment Validation and Entry

A data-entry system that helps collect, store, and transmit data needed for home healthcare evaluation.

Helps staff members at home health agencies meet data collection and submission requirements required of home healthcare agencies.

Home health care

35
Q

What are home healthcare agencies required to do?

A

Collect OASIS data and report survey information to their particualr state’s Department of Health Services survey agent. Info is stored for retrieval by the CMS.

36
Q

What are HHRGs?

A

Home health resource groups.

Like DRGs and APCs, HHRGs are paid based on predetermined base payment rates.

37
Q

What is a new payment system for ambulance services (including helicopters and airplanes)?

A

Ambulance Fee Schedule

38
Q

What are the seven categories of the Ambulance Fee Schedule?

A

1: Basic Life Support
2: Basic Life Support (emergency)
3: Advanced Life Support (Level 1)
4: Advanced Life Support (Level 1, emergency)
5: Advanced life support (Level 2)
6: Speciality care transport
7: Paramedic intercept.

39
Q

What are inpatient rehabilitation services?

A

Services provided to hospitalized patients to help them improve their ability to function independently, most often after some disability or trauma.

40
Q

What do inpatient rehabilitation facilities (IRF) provide?

A

Healthcare services with a concentration on patient rehab.

Examples: Physical therapy and occupational therapy.

41
Q

What is Physical therapy (PT)?

A

Treatment of disorders with physical methods such as massage, manipulation, and therapeutic exercise. Used to restore functioning after an illness or injury.

42
Q

How does the IRF PPS handle reimbursement?

A

IRF PPS takes information from a patient assessment instrument (PAI) to classify patients into distinct groups based on clinical characteristics and expected resource needs.

Pmts are then made based on classification assigned within the IRF PPS.

43
Q

What is occupational therapy (OT)?

A

Rehab designed to help people with physical, developmental, societal, or emotional deficits to build or regain skills for independence. Reimbursed inpatient rehab includes conditions like stroke, spinal cord injury, amputation, brain injury, hip fracture, burns, and others.

Medical Billing and Health Insurance (9 decks)

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