Various reimbursement methodologies

Question 1

What is the prospective payment system?

Answer 1

Reimbursement amount is determined before the patient receives healthcare services.

Question 2

What is the fee-for-service plan?

Answer 2

Reimbursement amount is provided after services.

Question 3

What does traditional insurance coverage use?

Answer 3

Fee-for-service

Question 4

What is the Chargemaster/Master Charge List/Charge Description Master?

Answer 4

List of healthcare supplies and services along with their specific charges. (itemization for everything used for patient treatment)

Linked to computerized billing system

Matches an item to a numeric code

Generates a specific payment amount

Question 5

What is traditional fee-for-service reimbursement?

Answer 5

When the patient or healthcare provider submits a claim to the third-party payer for healthcare services provided.

Covers medical expenses only. Mostly used by most healthcare offices today.

Question 6

How are traditional fee-for-service reimbursements calculated?

Answer 6

Fee schedules or Usual,Customary and Reasonable (UCR) Charges

Question 7

What is a fee schedule?

Answer 7

A list of maximum charges for a healthcare service provider under a fee-for-service basis.

Question 8

What are UCR charges?

Answer 8

They usually reflect the costs taht are the norm for a particular geographical area.

Question 9

What does the managed fee-for-service reimbursement involve?

Answer 9

Prospective and Retrospective review.

Question 10

What is the prospective review for managed fee-for-service?

Answer 10

Patients case is reviewed before health care services are delivered.

Question 11

What is an example of prospective review?

Answer 11

Pre-certification (or pre-admission certification)

Question 12

What is precertification?

Answer 12

Obtaining approval before treatment

Question 13

What is retrospective review?

Answer 13

Patient’s case is reviewed for appropriateness of service after discharge from hospital.

Question 14

What is utilization management?

Answer 14

The process that evaluates the necessity and appropriateness of various healthcare services.

Question 15

What is discharge planning?

Answer 15

Determining what the patient’s needs are after discharge. (is a type of utilization management)

Question 16

What is the difference between quality assurance and utilization management?

Answer 16

Quality assurance assesses the quality of care provided in a particular setting.

Utilization management review the appropriateness and necessity of the healthcare services.

Question 17

What is Episode-of-care (EOC) reimbursement?

Answer 17

One payment that is made to compensate providers for all the healthcare services provided to a patient for a specific period of time.

Question 18

What is capitation (in reference to EOC reimbursement)?

Answer 18

Reimbursement is based on pre-established payments for a specific period of time. (managed care plan pays the healthcare provider a fixed amount on a per capita (or person) basis. If reimbursed is more than needed then physician keeps additional payment. If services provided end up being more than capitated amount, physician doesn’t get reimbursed and thus loses money.

Question 19

What are global payments (in reference to EOC reimbursement)?

Answer 19

Made to the provider in one lump sum for all services given to the patient for a specific illness or disease.

Question 20

What are the two types of global payments?

Answer 20

Global surgery payments

Medicare ambulatory surgery payments.

Question 21

What is the ambulatory payment classification (APC) system? (formerly ambulatory patient groups APGS)

Answer 21

They are based on outpatient procedures performed and replace the preivous fee-for-service payment method for outpatient services.

Question 22

APC’s refer to what payment system?

Answer 22

One of ambulatory (or outpatient) procedures provided by ambulatory surgery centers.

Question 23

What are ambulatory surgery centers?

Answer 23

State-licensed suppliers of healthcare services that are certified by medicare. They use APC and outpatient prospective payment system (OPPS) for reimbursement classifications.