Unit 3 - Lesson 1: Reimbusement Methodologies

Question 1

Payments that hospitals receive from third-party payers for providing healthcare services

Answer 1

Accounts receivable (AR)

Question 2

Standard insurance claim form used to report outpatient services to insurance companies

Answer 2

CMS-1500 claim form

Question 3

Also known as crossover; group policy provision that helps determine the primary carrier in situations in which an insured party is covered by more than one policy, thus preventing the insured from receiving claims over payments

Answer 3

Coordination of benefits (COB)

Question 4

Statement sent to a participant in a health plan as well as the healthcare provider that lists services, amounts paid by the plan, and total amount billed to the patient

Answer 4

Explanation of benefits (EOB)

Question 5

Insurance companies contracted by the government to process claims for government insurance programs, such as Medicare part A and B

Answer 5

Fiscal intermediaries (FI)

Question 6

Communication from third-party payer to payee that provides a detailed accounting of payments and healthcare services provided

Answer 6

Remittance advice

Question 7

UB-92 payment codes for healthcare services or items

Answer 7

Revenue codes

Question 8

Also known as the CMS-1450 form, standardizes the processing of billing for hospital inpatient and outpatient services

Answer 8

UB-92 claim form

Question 9

The way that healthcare providers are paid for providing medical services

Answer 9

Reimbursement

Question 10

Doctors, hospitals, and healthcare facilities

Answer 10

Healthcare providers

Question 11

The process of assigning codes to certain pieces of information in the health record

Answer 11

Medical coding

Question 12

Illnesses that can be prevented before they occur by routine physical examinations and immunizations

Answer 12

Preventable health threats

Question 13

Responsible for providing an insurance arrangement that provides benefits in the form of healthcare service

Answer 13

Third-party payers

Question 14

Healthcare provider receives reimbursement based on the amount that they charge for service

Answer 14

Fee-for-service reimbursement

Question 15

Medical expenses that are listed in the benefits section of the insurance policy as being reimbursable by the insurance company

Answer 15

Covered medical expenses

Question 16

A list of healthcare supplies and services with specific charges assigned for each supply and service

Answer 16

Charge master

Question 17

The illness or trauma that brought the patient to the hospital

Answer 17

Admitting diagnosis

Question 18

A method that groups patients based on a specific set of characteristics, including principal diagnosis, procedures and/or resources being used

Answer 18

Case mix

Question 19

Additional illnesses present at the time of the patient’s admission to the hospital, often complicating treatment or prolonging patient’s hospital stay

Answer 19

Comorbidities

Question 20

The diagnosis, after examination and study, determined to be the cause of the patient’s admission to the hospital

Answer 20

Principal diagnosis

Question 21

Fee paid to hospital for services provided

Answer 21

Facility fee

Question 22

Fee paid to physician for services provided, such as medical consultation and surgery

Answer 22

Service fee

Question 23

A facility design for treating Medicare eligible patients

Answer 23

Skilled nursing facility

Question 24

A data set used in home health care for patient assessments to help monitor and improve the outcomes of home health care

Answer 24

Outcome and assessment information set (OASIS)

Question 25

Centers for Medicare and Medicaid services professional, universal health claim form; used by providers of outpatient health services for billing fees to health carriers

Answer 25

CMS– 1500

Question 26

Institutional claim form used by hospitals to receive payment from third-party payers; also known as the UB – 04 or the uniform bill

Answer 26

CM/S-1450

Question 27

Private companies that have a contract with Medicare to process Medicare part B bills for physicians and medical suppliers

Answer 27

Medicare carriers

Question 28

Information maintained on coding reviews and the actions needed for improvement

Answer 28

Audit trails

Question 29

Assigned codes that aren’t supported by the information in the patient’s health record

Answer 29

Up coding

Question 30

Codes that are normally assigned as a set or broken into separate codes for the purpose of obtaining higher reimbursement of healthcare services

Answer 30

Unbundling