Reimbursement Methods/Care Delivery

Question 1

What is an Indemnity Insurance Plan?

Answer 1

Indemnity benefits usually pays after the provider has billed the patient, the insured person is reimbursed by the company. Also known as fee-for-service where providers are paid for each service performed. It offers the most flexibility because they do not have restrictions which provider the insured can use.

Question 2

What is Capitation?

Question 3

What is Fee-for-Service?

Answer 3

Providers are paid for each service performed.

Question 4

What is DRG? (Diagnosis-Related Group)

Answer 4

A patient classification scheme that provides a means of relating the type of patient a hospital treats to the costs incurred by the hospital.
**It pays a predetermined amount based on the diagnosis rather than the actual cost of treating the patient. **

Question 5

What is Per Diem?

Answer 5

Hospital receives a* fixed amount per day* for the patient’s inpatient stay regardless of actual cost. Rate varies by service (medical, surgical, mental health, etc.) or can be uniform regardless of the intensity of services.

Question 6

Reverse Mortgages

Answer 6

• Line of credit is the most popular choices and often will not be considered an asset for Medicaid Eligibility.
• There are **NO **restrictions on what the money can be used for.
• The loan does not have to be repaid until the last borrower dies, sells, or moves out.
• Both spouses must be 62 or older to be listed on the deed.
• If one is only listed, and the spouse on the deed dies first, the surviving spouse will be required to repay the loan in full or be evicted.

Question 7

To qualify for Supplemental Security Income (SSI) total assets (not including primary residence and one car) must be less than?

Answer 7

$3000/mo. for a married couple and less than $2000/mo. for a single person.

Question 8

Who can deny a claim based on lack of medical necessity?

Answer 8

Only the Medical Director.

Question 9

Mr. Baker was fired from his job and elected COBRA coverage. On day 33 of his COBRA coverage he was declared disabled. How many months will Mr. Baker be eligible for COBRA coverage?

Answer 9

If an employee or dependent is qualified to receive COBRA due to termination or reduction of hours and then becomes disabled on or prior to day 60 of COBRA, it is extended to 29 months.

Question 10

COBRA coverage

Answer 10

Usual COBRA coverage for an employee who was voluntarily or involuntarily terminated or had a reduction in hours is 18 months.

Question 11

How long can a surviving spouse/children keep deceased health insurance under COBRA?

Answer 11

36 months

Question 12

What is the pharmacy benefits management’s primary goal?

Answer 12

To decrease the cost of prescription medications.

Question 13

How does the pharmacy benefit management decrease (control) the cost of RX’s

Answer 13

Contract with a network of retail pharmacies to provide medications at discounted rates, encourage use of generics and providing a formulary of low cost drugs.

Question 14

What is Case Mix Group (CMG)?

Answer 14

It determines the reimbursement rate for inpatient rehab facilities under Medicare.

Question 15

Under Medicare’s Inpatient Prospective Payment System; a hospital would be paid according to which payment classification system?

Answer 15

Medicare Severity Diagnosis Related Groups (MS-DRG).

Question 16

What is MS-DRG payment determined by?

Answer 16

The principal and the secondary diagnosis, ICD-9 procedures as well as patient’s gender, age, and discharge status.

Question 17

What is Coinsurance

Answer 17

A type of cost sharing. The percentage of billed charges that the member of a health plan pays for.

Question 18

What is Long Term Care Insurance?

Answer 18

An insurance policy that may offset some or all of the cost of long-term care. They vary widely, but usually have a limit on the dollar amount or number of years one can receive the benefit.

Question 19

What is Risk Sharing?

Answer 19

HMO and contracted provider each accept partial responsibility for the financial risk and rewards involved in cost-effectively care for the members enrolled in the plan and assigned to a specific provider.

Question 20

What is a viatical settlement?

Answer 20

A person with a terminal illness sells their life insurance policy to a third party for less than its mature value, in order to benefit from the proceeds while alive. It is usually free from federal income tax, the money received may impact eligibility for Medicaid, and there are no restrictions how the money can be used. The purchasing party becomes the beneficiary and takes responsibility for paying the premium.

Question 21

ESRD Medicare

Answer 21

A person entitled to Medicare solely because of ESRD is eligible to continue Medicare for 12 months after the month they no longer requires dialysis or 36 months after a successful kidney transplant.

Question 22

Medicare Part A Inpatient Hospital Care

Answer 22

Normally limited to 90 days during a benefit period. If the 90 days are exhausted, the beneficiary can elect to use days from a non-renewable “lifetime reserve” up to 60 days of inpatient hospital care.

Question 23

Medigap Supplemental Policies

Answer 23

It is offered by private insurance companies to cover out-of-pocket expenses.

Question 24

Inpatient Medicare Coverage Benefit Period

Answer 24

Begins the first day of admission and ends after they have been discharged for 60 consecutive days.

Question 25

Temporary Partial Disability (TPD)

Answer 25

Partially incapacitated for the length of the disability and is unable to perform normal work duties but can engage in modified work.

Question 26

Medicare provides benefits to…?

Answer 26

A person is entitled to Medicare based on disability after they have been entitled to SSD benefits for at least 24 months after a 5 month coordination period for a total of 29 months.

Question 27

MCG Care Guidelines in Utilization Review

Answer 27

Provides evidence-based care spanning the continuum of care, including ambulatory, inpatient, and surgical care, general recovery guidelines, recovery facility care, home care and BH guidelines.

Question 28

Mr. Miller became eligible for Medicaid in March. He applied for Medicaid November 1st.. Coverage begins when?

Answer 28

Up to 3 months prior to the month of application (August 1st)

Question 29

Third Party Administrators

Answer 29

They provide utilization review and process claims.

Question 30

Medical Necessity

Answer 30

Health plans define medical necessity as care that is appropriate, reasonable and necessary. Subjective terms and varies by health plan.

Question 31

Case Mix Group-CMG (Medicare)

Answer 31

Determines payment rates for Inpatient Rehab.
Uses Patient Assessment Instrument (PAI) which classifies patients into groups based on clinical characteristics and expected resource needs. PAI determines patient’s CMG, and the CMG determines payment rate per stay.

Question 32

Acclerated Death Benefits

Answer 32

Allows insured person to use some of the policy’s benefit prior to dying and deducted from the amount the beneficiaries receive at death. There are restrictions how it can be used. Usually used for long term care and medical expenses.

Question 33

Ambulatory Payment Classification System (APC)

Answer 33

Determines rates for ER, hospital based clinic, observation and ambulatory surgery.

Question 34

Worker’s Compensation…

Answer 34

Does not have a waiting period.

Question 35

Medicare Part A will cover SNF if……

Answer 35

It follows within 30 days of a hospital stay of at least 3 days and is medically necessary.

Question 36

Impact of Medication Adherence

Answer 36

Nearly 50-75% of adults are medication non-adherent in one or more ways.

Question 37

Hard Savings

Answer 37

Hard savings are directly related to the CM’s actions, i.e., decreased length of stay.

Question 38

Soft Savings

Answer 38

Soft savings are potential savings and are difficult to measure, i.e., avoidance of hospital readmission, prevention of medical complications, avoidance of ER visits.

Question 39

What is a Claims Adjuster?

Answer 39

An insurance professional who investigates claim by interviewing the claimant and other involved parties, reviews related records to determine the degree of liability and damages and assures that an insurance policy exists and covert ehs camined damages as well as assures medical care is available regarding the injury or occupational illness.

Question 40

What is cost-benefit analysis

Answer 40

It reveals whether the benefits of and action, intervention, service or treatment outweigh the coset and by how much so that the involved party is able to make the appropriate decisions.