Reinbursement Flashcards
What is a RUG?
Differentiate nursing home patients in skilled nursing facilities by level of resource use.
What is an APG and what do they cover?
A DRG for the ambulatory setting. Reimburse the cost of outpatient visits but do not cover physician costs.
Case management quality index(CMQI) based on what?
unit of analysis identified in the CEA (cost effective analysis) study
This is a process where an hmo and healthcare provider both accept portion of the responsibility for financial risk.
Risk sharing
How do EPO’s differ from PPO’s?
Have limitation with provider choice and not subject to as many laws as HMOs.
How does direct contract model work?
Contracts directly with individual physicians to provide all services to health plan members.
In UM review who determines covered benefits?
A customer service representative by checking for covered services.
What is the DRG case rate?
Rate of reimbursement that covers a certain category of service. Combined healthcare and provider fees.
Appeals of urgent denials must be decided within ___ and non urgent have ____.
72 h, 30 days
Medicare part A covers ——-
Part B covers ——
Hospitalization
Related services
What days of Medicaid benefit period require co insurance?
0-60 no co insurance
61-90 co insurance
91+ use of lifetime reserve or other payment type
