Health Care Reimbursement Methodologies

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I included the answers below but i don't know if my answers are correct please send me your opinions. thanks

1. Hospitals that are excluded from the Medicare acute care PPS
(such as children’s hospitals) are paid based on
A. reasonable costs..
B. fee schedules.
C. global payments
D. bundled payments.
2. If an enrollee uses more services than originally assumed per the PPPM calculation, then the plan would...
A. show a profit for that period.
B. show a loss for that period.
C. need a contract renegotiation.
D. require that the enrollee be dropped from the plan.

3. Which of the following reimbursement methohodologies determines payment before services are received?
A. Prospective payment system.
B. Retrospective payment system.
C. Fee-for-service payment system.
D. Capitation system.

4. Verifying the accuracy of ICD-9-CM and HCPCS codes is an important function in...
A. maintenance of chargemaster.
B. blended payment.
C. maintenance of the OASIS data set.
D. discounting.

5. After reviewing her case, the hospital moved her grandmother from inpatient care to a skilled nursing facility. This type of utilization control is used in...
A. discounting.
B. Home Assessment Validation and Entry.
C.maintence an audit trail.
D. discharge planning.

6. The process of reviewing a patient's need for services and treatment before the treatment is administered is known as...
A. utilization management.
B. precertification.
C. discharge planning.
D. global surgery determination.

7. A patient was admitted to the hospital with a heart attack and also hypertension, both of which required monitoring during the inpatient stay. The hypertention would be considered...
A. the principal diagnosis.
B. a complication.
C. a comorbidity.
D. the principal procedure.

8. Which of the following is based on per-person premium or membership fees?
A. Capitation.
B. Fee-for-service basis.
C. Medical savings account plans.
D. Retrospective payment system.

9. You work in a physician's office and have just submitted several claims to a commecial insurance company. Your office will probably be reimbursed based on a...
A. prosprctive payment system.
B. resource-based relative value system.
C. traditional fee-for-service system.
D. resource utilization group decision.

10. As a hospital health information management professional for Medicare coding, what might you use to help assign reimbusement classifications to episodes of care?
Possible Answers:
B. Resource-based relative scale.
C. Fee schedule.
D. Conversion factor.

11. A physician's overhead expenses are included in the...
A. chargemaster.
B. fee schedule
C. resource utilization group.
D. payment status indicator.

12. In a health care facility, who is responsible for processing accounts receivable, billing third-payers, and verifying insurance coverage?
A. Fiscal intermediaries.
B. Health information management professionals.
C. Patient accounts department staff.
D. Hospital administrators.

13. If an ambulatory surgery center is a separate entity distingushable from any other type of facility, it may qualify for...
A. Medicare payments.
B. Medicaid payments.
C. accreditation.
D. managed fee-for-service plan.
14. As a new health information management department director, you want to ensure that your department is adhering to the applicable state and federal coding guidlines and regulations. One way to ensure this is to...
A. contract with fiscal intermediary to code recfords.
B. review the chargemaster codes on an ongoing basis.
C. implement a coding compliance program.
D. participate in the electronic data interchange.

15. You're a radiologist working for a hospital's radiology depatment. How might you be paid?
A. By the hospital from its global payment.
B. By the patient directly
C. Through resource utilization groups.
D. Under the case-mix group payment rates.

16. Services under the outpatient prospective payment system are paid based on...
A. APC groups.
B. ABG groups.
C. RBRVS groups.

17. Basic life support, advance life support, and specialty care transport are all covered under what payment system?
A. Ambulance fee schedule
B. Inpatient rehabilitation prospective payment system
C. Home health resorce groups
D. Skilled nursing facility PPS.

18. Who is reponsible for adjusting the Medicare DRG list and reimbusement rates annually?

19. Your hospital has just received a reimbursement rejection from the fiscal intermediary for two outpatient procedures that were performed on the same day. This rejection was probably generated by...
A. the CCI outpatient code editotor
B. the DRG grouper
C. the internal auditing program
D. the HAVEN softwar.

20. Which of the following hospital administrators most likely use to make decisions about inpatient services?
A. Medicare fee schedule
B. Case-mix group data
C. Payment staus indicators
D. Revenue codes.

1. A 11. B
2. B 12. C
3. A 13. D
4. A 14. C
5. D 15. A
6. B 16. A
7. C 17. A
8. A 18. C
9. C 19. A
10. C 20. D or B

  • Health Care Reimbursement Methodologies -

    I took the test and these were the right answers 100%

    1. A 11. B
    2. B 12. C
    3. A 13. A
    4. A 14. C
    5. D 15. A
    6. B 16. A
    7. C 17. A
    8. A 18. C
    9. C 19. A
    10.A 20.B

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