Domain 4:Subdomain 1 Flashcards
A classification system to group cases into groups expected to use similar amounts of resources. It was developed for Medicare and used as part of the PPS for reimbursement.
DRG: Diagnosis Related Group
System that is based on a predetermined, fixed amount.
PPS: Prospective Payment System
Case-mix management system that utilizes data from the MDS in long-term care settings/ SNFs.
RUG: Resource Utilization Group
A scale of uniformed relative values for all physicians’ services in outpatient settings.
RBRVS: Resource-Based Relative Value Scale
RBRVS comprises these three elements. What are they?
Malpractice, Physician work, and Physician practice expense
The prospective payment system based on resource utilization groups (RUGs) is used for reimbursement to ___________ for patients with Medicare.
skilled nursing facilities
What are the three major steps in a patient’s hospital stay from an insurance company’s point of view?
Admission, treatment, discharge
Measure of the clinical severity or resource equipment
Case-mix index
Medicare payment system for hospital services that determines the number of hospital stays and hospital services that are reimbursed.
Inpatient prospective payment system (IPPS)
Payment system for Medicare Part B services that facilities provided on an outpatient basis.
Outpatient prospective payment system (OPPS)
What are two important guidelines that apply to OPPS billing?
The inpatient only list and the three day payment window rule
Paper claim for hospital billing, Monitored by the National uniformed billing committee.
UB 04
Medicare-refinement of the diagnosis-related group (DRG) payment system. This allows payment to be closely aligned to resource intensity
Medicare-severity diagnosis-related group (MS-DRG)
All of the following items are “packaged” under the Medicare outpatient prospective payment system, except:
a. medical visits
b. medical supplies
c. anesthesia
d. recovery room
a. medical visits
Under the RBRVS, each HCPCS/CPT code contains three components. Each having assigned relative value units. What are they?
Malpractice insurance expense, practice expense, and physician work
The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called.
APCs
A patient was seen by Dr. Hope. The charge for the office visit was $200. The Medicare beneficiary had already met his deductible. The Medicare fee schedule amount is $100. Dr. Hope does not accept assignment. The office manager will apply a practice term which is called “balance billing,”what does this term mean
It means that the patient is financially liable for charges in excess of the Medicare fee schedule, up to a limit
Rewarding providers for delivering high-quality, efficient clinical care
Value based purchasing (VBP)
All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue
Revenue cycle management
A network of healthcare providers who provide services to those enrolled in the ________.Reimbursement is based either on a contracted fee based off an identified fee schedule or a defined pre-established discounted amount. Providers may elect to join a PPO as a means to increase patient volume while providing services via a discounted fee schedule.
PPO
