Question: When an insurance carrier makes a payment to the patient/insured (or the provider) for a covered expense, it is referred to as

Answer: reimbursement

Question: A payment system whereby the healthcare provider is paid a fee for each service or supply provided and fees are billed at rates established by the provider is referred to as

Answer: fee-for-service

Question: A type of reimbursement used by CMS that bases Medicare payments on a predetermined, fixed amount (e.g., DRGs for inpatient hospital services) is called

Answer: prospective payment system

Question: The amount of payment in the PPS (based on the classification system of that service) is determined by the assigned

Answer: diagnosis-related group (DRG)

Question: A method of payment for healthcare services whereby the provider is paid a fixed amount for each patient regardless of the actual number or nature of services provided is called

Answer: capitation

Question: The Medicare Prospective Payment System (PPS) for acute inpatient hospital care was mandated by the

Answer: Social Security Amendments of 1983

Question: Which organization has been given primary authority for putting the PPS into practice?

Answer: Centers for Medicare and Medicaid Services (CSM)

Question: Medicare's inpatient hospital classification system used to pay a hospital or other provider for services, categorizing illness or conditions by diagnosis and treatment, is called

Answer: DRG

Question: The Omnibus Budget Reconciliation Act of 1989 (OBRA89) legislated a system to replace the UCR method of generating professional fees called the

Answer: resource-based relative value scale (RBRVS)

Question: When determining the applicable DRG classification, the key piece of information is the patient's

Answer: principal diagnosis

Question: The presence of more than one disease or health condition in an individual at a given time is called

Answer: comorbidity

Question: A computer software program that identifies a patient's DRG category by interpreting certain coded information is called

Answer: DRG grouper

Question: The service classification system that was designed to explain the amount and type of resources used in an outpatient encounter is called

Answer: APCs

Question: When determining the APC payment rate,the coding and classification of services provided to the patient are based on the ___________ coding system

Answer: CPT

Question: Resource utilization group (RUGs) are used to calculate payments according to severity and level of care in

Answer: skilled nursing facilities

Question: The acronym for a factor used by Medicare to adjust relative value unit (RVU) weights for various localities in the United States that have differing costs for providing healthcare is the

Answer: GPCI

Question: Medicare's payment system for reimbursing hospitals for providing inpatient care to beneficiaries is refered to as

Answer: IPPS

Question: Under Medicare's PPS, long-term care hospitals (LTCHs) generally treat patients who require hospital-level care for an average of ________ days.

Answer: 25

Question: The federal payment rate adjustment for LTCH stays that are significantly shorter than the average length of stay for a long-term care DRG is referred to as

Answer: a short-stay outlier

Question: In the Home Health Prospective Payment System (HHPPS), determination of payment is dependent on

Answer: OASIS

Question: The organization (composed of physicians and other healthcare professionals) that the federal government pays to evaluate services and monitor the quality of patient care provided by other practitioners is the

Answer: PRO

Question: An agreement between the provider and third-party payer whereby the provider agrees to accept the payer's allowed fee as payment in full for a particular service or procedure is referred to as

Answer: a contractual write-of

Question: The federal entity that sets guidelines and rules that affect the entire healthcare industry and that everyone in this industry must follow is the

Answer: Centers for Medicare and Medicaid Services (CMS)

Question: NonPARs not accepting assignment can charge beneficiaries no more than ________ percent of the Medicare allowed fee.

Answer: 115

Question: More and more practices are converting to a provider fee schedule that is based on

Answer: RVUs

Question: T/F. Medicare beneficiaries are the only patients who are included in the PPS system.

Answer: F

Question: T/F. When treating a typical inpatient in a given DRG, prospective payment rates are set at a level intended to cover operating costs.

Answer: T

Question: T/F. Hospitals are paid a set fee for treating patients in a single DRG category under Medicare's PPS, regardless of the actual cost of care for the individual.

Answer: T

Question: T/F. The established payment rate for all services that a patient in an acute care hospital receives is based on the highest payment level experienced in the DRG category.

Answer: F

Question: T/F. The biggest challenge in developing an RVS-based payment schedule was patient diversity.

Answer: F

Question: T/F. Balance billing is allowed with the RBRVS system.

Answer: F

Question: T/F The DRG reimbursement system is used in both Medicare and Medicaid healthcare programs.

Answer: T

Question: T/F. DRG grouping is based on the admitting diagnosis only.

Answer: F

Question: T/F. The principal procedure and the principal diagnosis determine the DRG assignment.

Answer: T

Question: T/F. Relative weights (RWs) and arithmetic lenght of stay (ALOS) both affect DRGs.

Answer: T

Question: T/F. Resource utilization groups (RUGs) are used to calculate payments to a skilled nursing facility (SNF) according to severity and level of care.

Answer: T

Question: T/F. RUGs are behaviors related to mental health.

Answer: F

Question: T/F. Congress establishes all Medicare and Medicaid payment rules.

Answer: F

Question: T/F. PPS is Medicare's system for reimbursing Part A inpatient hospital cost, and the amount of payment is determined by the assigned diagnosis-related group (DRG).

Answer: T

Question: T/F. DRG payments for each hospital are adjusted for differences in area wages, teaching activity, care to the poor, and other factors.

Answer: T

Question: T/F. EMTLA mandated that CMS implement an inpatient rehabilitation facility prospective payment system (IRF PPS).

Answer: F

Question: T/F. In the IRF PPS, reimbursement is based on the length of the patient's hospital stay.

Answer: F

Question: T/F. Peer review organizations (PROs) only deal with organizations that involve healthcare.

Answer: F

Question: T/F. Purchasing an expensive and intricate medical billing system is a way of ensuring that a medical practice will be satisfied.

Answer: F

Question: T/F. Bad-debt write-offs are different from contractural write-offs.

Answer: T

Question: T/F. HIPAA demanded that all medical facilities be computerized by October of 2003 without exception.

Answer: F

Question: T/F. Congress mandates that all medical facilities use the same format for submitting electronic health transactions.

Answer: F

Question: The Joint Commission (formerly JCAHO) has specific standards for all electronic transactions.

Answer: F

Question: T/F. It is important to make sure products are in compliance with the HIPPA Privacy Rule when selecting a hardware/software vendor.

Answer: T

Question: T/F. When a medical practice contracts with a "business associate," unless the business is medically related, the agreement does not have to abide by HIPAA regulations.

Answer: F

Question: Organization that have the ability to force hospitals to comply with HHS admission and quality standards are called

Answer: Peer review organization (PRO)

Question: A common method of reimbursement used primarily by HMOs, in which the provider or healthcare facility is paid a fixed, per capita amount for each person enrolled in the plan without regard to the actual number or nature of services provided, is called

Answer: capitation

Question: A system of classifying hospital inpatient cases into categories with similar use of the facility's resources is

Answer: Diagnosis-related groups (DRGs)

Question: The acronym for the system designed to explain the amount and type of resources used in an outpatient encounter is__________.

Answer: Ambulatory payment classification (APC)

Question: The process of adjusting or canceling the balance on a patient's account after all deductibles, coinsurance amounts, and third-party payments have been made is called __________.

Answer: Contractual write-off