Discuss Other Various Payment Systems

Question 1

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

Answer 1

Resource-based relative value scale (RBRVS)

Question 2

What is the facility fee?

Answer 2

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

Question 3

Do physicians split the facility fee with hospitals or?

Answer 3

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

Question 4

What is service fees?

Answer 4

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

Question 5

What is the RBRVS system based on?

Answer 5

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

Question 6

What is the formula that RBRVS systems are based on?

Answer 6

• 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]

Question 7

What is the RVUw?

Answer 7

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

Question 8

What is RVUpe?

Answer 8

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

Question 9

What is RVUm?

Answer 9

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

Question 10

Where does the CMS publish the RVUs?

Answer 10

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)

Question 11

What is the RBRVS system used for?

Answer 11

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

Question 12

What is the RBRVS system based on?

Answer 12

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)

Question 13

What is the conversion factor?

Answer 13

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

Question 14

What is a skilled nursing facility (SNF)?

Answer 14

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

Question 15

When is SNF care needed?

Answer 15

Generally only a short period of time after a hospitalization.

Question 16

What does treatment in SNFs include?

Answer 16

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

Question 17

When is a person no longer qualified for SNF care?

Answer 17

When a person doesn’t require continuous medical evaluation.

Question 18

What is per diem?

Answer 18

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

Question 19

What is reasonable cost?

Answer 19

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

Question 20

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

Answer 20

MS-DRGs

Question 21

What do physician offices use for reimbursement?

Answer 21

RBRVS systems.

Question 22

What does the SNF PPS use for reimbursement?

Answer 22

Resource utilization groups (RUGs) .

Question 23

How does the RUG system work?

Answer 23

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).

Question 24

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

Answer 24

RAVEN: Resident Assessment Validation and Entry.

Question 25

What is RAVEN?

Answer 25

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

Question 26

What are historical costs?

Answer 26

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

Question 27

What is OPPS?

Answer 27

Outpatient prospective payment system.

Question 28

What does OPPS do?

Answer 28

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

Question 29

What is the OPPS based on?

Answer 29

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

Question 30

How do APCs work?

Answer 30

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.

Question 31

What is a home health agency (HHA)?

Answer 31

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

Question 32

What is OASIS?

Answer 32

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.

Question 33

What is OASIS important for?

Answer 33

-Patient Assessment and care planning -Case-mix and statistical reports -Performance improvement.

Question 34

What is HAVEN?

Answer 34

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

Question 35

What are home healthcare agencies required to do?

Answer 35

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.

Question 36

What are HHRGs?

Answer 36

Home health resource groups. Like DRGs and APCs, HHRGs are paid based on predetermined base payment rates.

Question 37

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

Answer 37

Ambulance Fee Schedule

Question 38

What are the seven categories of the Ambulance Fee Schedule?

Answer 38

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.

Question 39

What are inpatient rehabilitation services?

Answer 39

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

Question 40

What do inpatient rehabilitation facilities (IRF) provide?

Answer 40

Healthcare services with a concentration on patient rehab. Examples: Physical therapy and occupational therapy.

Question 41

What is Physical therapy (PT)?

Answer 41

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

Question 42

How does the IRF PPS handle reimbursement?

Answer 42

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.

Question 43

What is occupational therapy (OT)?

Answer 43

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.