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158 Cards in this Set
- Front
- Back
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The national health service (Beveridge) model is different from the social insurance (Bismark) model because the Beveridge model is financed by general revenue funds from fiscal taxes, whereas the Bismarck model is financed by workers' and employers' compulsory payroll contributions into sickness funds.
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True
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What are the four characteristics of the US healthcare sector?
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*Size of economic sector *complexity
*intricate payment methods and rules *broad program scopes |
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The federal role in the healthcare sector is limited to paying providers for the healthcare costs of senior citizens.
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False
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What do insurers receive in return for assuming the insureds' exposure to risk or loss?
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premium payments
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Insurers pool premium payments for all the insureds in a group, then use actuarial data to calculate the group's premiums so that:
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The pool is large enough to pay losses of the entire group
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Where and when did health insurance become established in the United States?
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1929, Texas - Blue Cross covered school teachers.
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What is the term for health insurance that only covers the employee?
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individual (single) coverage
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What term in healthcare means compensation or repayment for rendering healthcare services?
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reimbursement
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Who is the third party in healthcare situations?
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Payer
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All of the following are types of episode-of-care reimbursement except:
*Global payment *Prospective payment *Capitation *Self insured plan |
Self insured plan
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What discounted fee schedule does Medicare use to reimburse physicians?
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RBRVS - resource-based relative value scale
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Name and describe some versions of the global payment method.
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*Global payment method - the 3rd party payer makes one combined payment to cover the services of multiple providers who are treating a single episode of care.
*-block grant - a fixed amount of money given or allocated for a specific purpose. *-total episode of care - a single price that covers costs across the continuum of care. *-bundling - combines into a single prospective payment to costs of dialysis services, injectable drugs, laboratory tests, and medical equipment and supplies. |
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Which one of the three models of healthcare delivery is used in the United States?
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Private health insurance model
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Why is the US federal government a dominant player in the healthcare situations?
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The federal Medicare program is the largest single payer for health services in the US. Medicaid, a joint state-federal program, is the largest source of federal revenue for states. Medicare also provides significant funds for medical education, research, and the care of disadvantaged and vulnerable people. Because of the size of the federal role in healthcare reimbursement, any changes that the federal government makes in its reimbursement methods profoundly affects providers, other health insures, and the healthcare system. Federal government also pays for health services for other populations including active duty and retired military personnel and their families, veterans, Native Americans, and injured and disabled workers
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Who are the first, second, and third parties in healthcare situations?
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*1st party - the patient or the person responsible for the patient's health bill
*2nd party - provider *3rd party - payer |
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Compare the UCR and CPR payment systems.
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They are both discounted fee-for-service payment methods.
UCR - usual, customary, and reasonable CPR - customary, prevailing, and reasonable UCR is defined as usual in the provider's practice, customary in the community, and reasonable for the situation. CPR is defined as customary in the providers' practice, prevailing in the community, and reasonable as the provider's lowest actual charge. |
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Describe the two purposes of managed care.
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The two purposes of the management or control are to reduce the costs of healthcare for which the 3rd party payer must reimburse the providers and to ensure continuing quality of care.
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Why have many insurers replaced retrospective health insurance plans with group plans such as HMOs and PPOs?
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The retrospective fee-for-service payment method has the disadvantage of great uncertainty. The payers have no way of knowing the total charges that will be incurred and for which they must reimburse the providers. In managed care, HMOs and PPOs, reimbursement methods, third party payers, can manage both the costs of healthcare and the outcomes of care. The third-party payer has implemented some provisions to control the costs of healthcare while maintaining quality care.
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What are advantages of capitated payments for providers and payers?
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The advantages of capitated payment are that the third-party payer has no uncertainty and that the provider has a guaranteed customer base.
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How do third-party payers set per diem payment rates?
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using historical data - the total costs for all inpatient services for a population during a period are divided by the sum of the lengths of stay in the period. To determine the payment, the per diem rate is multiplied by the number of days of hospitalization.
if no historical data - they must consider several factors to establish per diem rates. These factors include costs, length of stay, volumes of service, and patients' severity of illness |
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Describe the major benefits of episode-of-care reimbursement according to its advocates, as well as the major concerns about episode-of-care reimbursement expressed by its critics.
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Benefits - Healthcare analysts, like the savings associated with eliminating wasteful or unnecessary procedures and tests. They believe that the volume of expensive testing is not necessary and does not define quality.
Critics - Consumer advocates are concerned that the payment method creates incentives to substitute less expensive diagnostic and therapeutic procedures and laboratory and radiological tests and can delay or deny procedures and treatments. |
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Why is the constant trend of increased national spending on healthcare a concern?
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It is a concern because money is a limited resource. When spending on healthcare increases, the money available for other sectors of the economy decreases. Experts at the HCCI state that "rising healthcare costs are stifling economic growth, consuming increasing portions of the nation's gross domestic product, and putting added burdens on businesses, the public sector, individuals, and families."
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Which of the following is NOT an episode-of-care reimbursement methodology?
*Global payment *Managed Care *Capitated payment *Prospective payment |
Managed Care
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Payers that use per-diem payment rates reimburse the provider a fixed rate for each day a covered member is hospitalized.
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True
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The bill that the pathologist's office submitted for a laboratory test was $54.00. In its payment notice (remittance advice), the healthcare plan lists its payment for the laboratory test as $28.00. What does the amount of $54.00 represent?
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Charge
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From the patient's healthcare insurance plan, the rehabilitation facility received a fixed, pre-established payment for the patient rehabilitation after a total knee replacement. What type of healthcare payment method was the patient's healthcare insurance plan using?
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Case-based
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The constant trend of increased national spending on healthcare is a concern because as spending on healthcare increases, the money available for other sectors of the economy decreases.
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True
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The financial manager of a physician group practice explained that the healthcare insurance company would be reimbursing the practice for its treatment of the exacerbation of congestive heart failure that Mrs. Zale experienced. The exacerbation, treatment, and resolution covered approximately five weeks. The payment covered all the services that Mrs. Zale incurred during the period. What method of reimbursement was the physician group practice receiving?
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Episode-of-care
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Which healthcare payment method does Medicare use to reimburse physicians based on the cost of providing services in terms of effort, overhead, and malpractice insurance?
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Resource-based relative value scale
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In the healthcare industry, what is another term for "charge"?
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Fee
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A physician's office sent a request for payment to State Farm Insurance Company. The term used in the healthcare industry for this request for payment is a(n):
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Claim
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There are 3 parties in healthcare reimbursement. Who is the third party?
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Payer
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Which act promoted the adoption and use of EHR's and other health information and communication technologies?
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HITECH
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In which type of reimbursement methodology do healthcare insurance companies reimburse providers after the costs have been incurred?
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Retrospective payment
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Dr. Little has an agreement with the health plan for Smith Manufacturing to reimburse Dr. Little $20 per employee per month. In January Dr. Little saw 50 patients from Smith Manufacturing. Smith Manufacturing has 300 employees so Dr. Little received $6000 from the health plan. What method is the health plan using to reimburse Dr. Little?
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Capitated rate
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In which type of reimbursement methodology does the health insurance company have the greatest degree of risk?
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Retrospective
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What is the purpose of managed care?
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To reduce the costs of healthcare services &
To improve the quality of care for patients |
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In the United States, what is healthcare insurance?
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Reduction of a person's or a group's exposure to risk for unknown healthcare costs by the assumption of that risk by an entity
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Which statement describes the per diem payment method?
*Consolidation of all types of services, such as speech, physical, and occupational therapy, into a single lump sum payment *Monthly payment of $4,500 representing $15 for each of 300 enrollees *Fixed rate for each day a covered member is hospitalized *Payment for each service that a physician renders |
Fixed rate for each day a covered member is hospitalized
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The 1st party when referring to healthcare finances is always the patient
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False
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Which of the three models for health systems predominates in the United States?
*Social insurance (Bismarck) model *National Health Service (Beveridge) model *Private health insurance model |
Private health insurance model
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All of the following are discounted fee-for-service healthcare payment methods EXCEPT:
*APG's (Ambulatory patient groups) *CPR (Customary, prevailing and reasonable) *RBRVS (Resource-based relative value scale) *UCR (Usual, customary, and reasonable) |
APG's (Ambulatory patient groups)
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In which type of healthcare payment method does the healthcare plan pay for each service that a provider renders?
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Fee-for-service reimbursement
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In which type of reimbursement methodology do healthcare insurance companies determine payment to providers before the services have been delivered?
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Prospective payment
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There are 3 parties in healthcare reimbursement. Who is the second party?
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Provider of care or services
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All of the following methods are types of episode-of-care reimbursement EXCEPT:
*Global payment *Prospective payment *Capitation *Self-insured plan |
Self-insured plan
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How could a group of physicians increase the monthly payments the group receives from a healthcare plan that uses capitation?
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Renegotiate the contract
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The code sets to be used for healthcare services reporting by both public and private insurers were designated by what legislation?
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HIPAA of 1996
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The first three characters in an ICD-10-CM diagnosis code represent its:
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Category
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What organizations maintain the ICD-10-CM/PCS code set?
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NCHS and CMS
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Where are the ICD-10-CM/PCS coding guidelines published?
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The official coding guidelines for ICD-10-CM are available for download from the NCHS website. The official coding guidelines for ICD-10-PCS are available for download from the CMS website. Additional guidelines are published by the AHA in Coding Clinic for ICD-10-CM and ICD-10-PCS quarterly.
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What code set was incorporated into the Healthcare Common Procedure Coding System as HCPCS Level I?
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CPT
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The new coding assistant at the Glen Ellyn Medical Group office coded and submitted a claim to Blue Cross for an initial evaluation and management office visit when, in fact, the patient was established with the practice and was seen strictly for a follow-up medical check. The resulting error was an example of ______________.
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abuse
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All of the following are efforts to fight healthcare fraud and abuse except:
*Operation Restore Trust. *Medicare Integrity Program. *Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. *Medicare and Medicaid Patient and Program Protection Act of 1987. |
Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982.
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What legislation supports the CERT program?
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IPERA and IPERIA
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What differentiates recovery auditors from other entities performing improper payment reviews?
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Unlike other improper payment review entities, recovery auditors are reimbursed via a contingency fee based on the amount of improper payments identified and successfully collected.
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What are the core areas of the coding compliance plan?
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The core areas of the coding compliance plan are policies and procedures, education and training, and auditing and monitoring.
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ICD
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Diagnoses and inpatient procedures
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HCPCS Level II
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Medical and surgical supplies
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CPT
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Physician inpatient or outpatient procedures
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Common forms of fraud and abuse include all of the following except:
*Upcoding. *Unbundling. *Refiling claims after denials. *Billing for services not furnished to patients. |
Refiling claims after denials.
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Name three of the seven OIG elements of an effective compliance plan.
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*Written policies and procedures
*Designation of a compliance officer *Education and Training |
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The CERT program was established to correct improper payments.
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False
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Describe the importance of the RAC prepayment review demonstration project.
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The review revealed that more than 58% of the reviewed claims were improperly billed. The improper billing resulted in $22.3 million in saving to the Medicare Trust Fund it allowed CMS to identify error claims prior to paying and for such claims.
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What resource can managers use to discover current target areas of compliance?
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The OIG Work Plan
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What two forms of benchmarking can be used to determine a staff's level of compliance?
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Internal - allows the manager to examine reporting rates over time and helps the manager pinpoint the specific period when a compliance issue arose.
External - or peer comparison helps a manager to know how his or her team has performed compared with peers. |
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The ICD is maintained by the American Medical Association.
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False
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The policies and procedures section of a Coding Compliance Plan should include:
*Upcoding *Coding medical records without complete documentation *Correct use of encoding software *All of the above |
All of the above
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The practice of under-coding can affect a hospital's MS-DRG case-mix in which of the following ways?
*Makes it lower than warranted by the actual service/resource intensity of the facility *Makes it higher than warranted by the actual service/resource intensity of the facility *Does not affect the hospitals MS-DRG case mix *Coding has nothing to do with a hospital's MS-DRG case mix |
Makes it lower than warranted by the actual service/resource intensity of the facility
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PERM and CERT were created under which act and its amendments?
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Improper Payments Information Act of 2002
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Recovery Audit Contractors are different from other improper payment review contractors because:
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RACs are reimbursed on a contingency-based system
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CPT is published by:
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AMA
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Internal and external benchmarking can:
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Help a manager determine a staff's level of coding compliance
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Which of the following is a correct format for a CPT code Category 1?
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12345
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The coding system that is used primarily for reporting diagnoses for hospital inpatients is known as:
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ICD-10-CM
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Which governmental fraud and abuse effort targeted 5 states and made a major push for accurate coding and billing? They recovered $188 million during the the 1st 2 years and paved the way for implementation of a national toll free fraud and abuse hotline.
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Operation Restore Trust
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Which of the following entities does not perform improper payment reviews for CMS?
*QIO *CERT *RACs *MACs *None of the above |
None of the above
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Which of the following coding systems was created for reporting procedures and services performed by physicians in clinical practice?
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CPT
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Abuse occurs in Medicare billing when:
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A healthcare provider unknowingly or unintentionally submits an inaccurate claim
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The Health Insurance Portability and Accountability Act of 1996 is widely known for:
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Its security and privacy provisions
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Fraud occurs in Medicare billing when:
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There is an intentional representation that an individual knows to be false, knowing that the representation could result in some unauthorized benefit to him/her or some other person
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Which of the following is the correct format for HCPCS Level II codes?
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A1234
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What can help a manager determine the coding staff's level of coding compliance?
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Internal and External benchmarking
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Which of the following would NOT be part of a coding compliance plan?
*Physician query process *Making sure coding salaries are competitive *Coding medical records without complete documentation *Correct use of encoding software |
Making sure coding salaries are competitive
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Which of the following is charged with identifying under-payments and over-payments for Medicare?
*CMS *Officer of Inspector General *HIPAA *Recovery Audit Contractors |
Recovery Audit Contractors
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The RAC appeals process has _________ levels.
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5
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The publication for coding guidelines and advice in ICD-10-CM and PCS is:
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Coding Clinic
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Which of the following is an example of fraud?
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Billing for a service not furnished as represented on the claim
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Who released the 7 elements to serve as an effective corporate compliance plan?
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Office of Inspector General
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The publication for coding issues and guidance in CPT coding is:
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CPT assistant
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CPT category III codes represent:
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Emerging technology
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Which type of RAC review combines data analysis and submission of medical records to the RAC?
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Semi-automated
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When people purchase healthcare insurance for themselves and their dependents, they are purchasing single coverage.
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False
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In terms of healthcare insurance coverage, both children and spouses may be considered dependents.
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True
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In the healthcare insurance sector, which type or risk pool has the greatest diversity and the greatest ability to balance risks?
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large employer pools
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Individual (private) healthcare insurance is the most common means of coverage for the non-elderly in the United States.
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False
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What organization is one of the most influential in the healthcare sector? Why?
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BCBSA - they insure one in three Americans and is contracted by the federal government for certain aspects of Medicare and Medicaid
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Who is included in a healthcare insurance policy offering dependent healthcare coverage?
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SUBSCRIBERS OR EMPLOYEES, THEMSELVES, AND THEIR DEPENDENTS, IF APPLICABLE.
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Which two types of policies offer the widest ranging coverage but require the insured to pay coinsurance until the maximum out-of-pocket costs are met?
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Commercial - employer based and private Blue Cross and Blue Shield comprehensive policies and essential policies
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Which of the following is not a type of healthcare policy limitation?
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Geographic plan
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Which type of prescription drug, generic or nonformulary, is less costly for insureds using their drug benefit?
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generic
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Describe the types of procedures and services that typically require prior approval.
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*outpatient surgeries,
*diagnostic, international, and therapeutic outpatient procedures, *physical, occupational, and speech therapies, *mental health and chemical dependency care, *inpatient care - including surgery, *home health, private nurses, and nursing homes, *organ transplants |
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Both parents carried healthcare insurance with dependent coverage through their employers. What procedure is used to determine which healthcare insurer is responsible for their child's health expenses?
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dependent child's primary insurer: insurance of parent whose birthday comes first in calendar year "birthday rule"
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When a patient's healthcare services are covered under a voluntary healthcare insurance plan, who pays the remainder of a healthcare bill after the healthcare insurance company has paid?
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policy holder or insured
guarantor |
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The patient and the guarantor are always the same person.
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False
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What is the term for the number that identifies the employer, association, or other entity purchasing the healthcare insurance and indicates a common set of healthcare benefits?
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Group
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The actual charge is the same as the allowable charge.
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False
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What is the term for the difference between the provider's actual charge and the allowable charge?
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adjustment or write-off
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Describe the health insurance plan that covers federal government employees.
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Blue Cross Blue Shield-Federal Employee Program (FEP) and also known as the Service Benefit Plan
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What is the relationship between covered conditions and covered services in health insurance plans?
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Covered conditions are patient diseases or injuries for which the healthcare plan will pay. The covered services are related to the treatment for the covered conditions.
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What type of insurance policy provides benefits to (a) a resident requiring nursing home care and services, (b) an insured who becomes blind, and (c) a homeowner who requires an eight-month recuperation after a fall down her basement stairs?
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a - long-term (extended) care policies
b - accidental death and dismemberment (loss) policies c - disability income protection policies |
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Name at least two of the three benefit terms that mean the amount beyond which all covered healthcare services for an insured or dependent are paid 100 percent by the insurance plan.
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*Stop-loss benefits,
*maximum out-of-pocket cost, *catastrophic expense limit |
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Copayments are cost-sharing provisions of policies that require insureds to pay a flat fee to healthcare service providers and suppliers.
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True
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Why can use of a formulary be considered a policy limitation?
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In the case of prescription drugs, the insurance policy covers generic drugs, or Tier 1 drugs, better than a Tier 5 drug due to the cost of the drug. Generic drugs are cheaper; therefore, the policy limits how it pays for prescriptions.
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List at least three typical exclusions found in insurance plan riders.
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*experimental or investigational diagnostic and therapeutic procedures
*source of injury treatments, such as for war related injuries and injuries sustained in the course of risky recreational activities *cosmetic procedures |
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How does Blue Cross and Blue Shield notify insureds about the extent of payments made on a claim? What data elements does that notification include?
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EOB - explanation of benefits
*details how the healthcare insurance company determined its payment for the healthcare services |
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Why should providers submit clean claims to third-party payers?
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it speeds accurate and correct reimbursement
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Out-of-pocket costs for subscribers and patients are decreasing.
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False
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In private or commercial healthcare insurance plans, covered conditions are patient conditions, diseases, or injuries for which the healthcare plan will pay and, correspondingly, covered services are services related to treating the covered conditions, diseases, or injuries.
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True
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All of the following types of procedures and services typically require prior approval EXCEPT:
*Emergency services for suspected stroke *Outpatient surgery *Mental health and chemical dependency care *Inpatient care including surgery *Physical, occupational, and speech therapies |
Emergency services for suspected stroke
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All of the following specifications are types of limitations on healthcare policies EXCEPT: *Benefit cap
*Cost-sharing provision *Geographic plan *Use of formulary |
Geographic plan
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Both parents of a dependent child had employer-based group health insurance. Per the "birthday rule," the primary payer for the dependent child is the insurance of the parent whose birthday comes first in the calendar year.
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True
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Which of the following does a policyholder Not pay?
* A write off *Deductible *Premium *Co-payment |
A write off
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Which types of prescription drug is the LEAST costly for insureds using their drug benefit?
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Preferred generic
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From a remittance advice, providers can determine how much money they can:
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Write off
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Which of the following characteristics is the greatest advantage of group healthcare insurance?
*More stringent preexisting condition restrictions *Smaller risk pool *Greater benefits for lower premiums *Higher out-of-pocket expenses |
Greater benefits for lower premiums
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What healthcare organization is one of the most influential in the healthcare sector because it insures nearly one in three Americans?
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BCBSA
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Which type of healthcare insurance policy offers the widest ranging coverage but requires the insured to pay coinsurance until the maximum out-of-pocket costs are met?
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Comprehensive
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In regards to health insurance, the percentage that the guarantor pays is called the:
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Coinsurance
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What is the term for the contract between the healthcare insurance company and the individual or group for whom the company is assuming the risk?
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Policy
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In the healthcare industry all of the following benefits terms mean the amount during a time-frame beyond which all covered healthcare services for an insured or dependent are paid 100 percent by the insurance plan EXCEPT:
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Rider
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All of the following entities are voluntary healthcare insurance EXCEPT:
*Private healthcare insurance plans *Commercial healthcare insurance plans *Medicare *Blue Cross and Blue Shield |
Medicare
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Which type of healthcare insurance policy provides benefits to an insured who is blinded as the result of an accident?
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Accidental death and dismemberment insurance
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A group of individual entities whose healthcare costs are combined for evaluating financial history and estimating future costs is:
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A risk pool
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Which type of healthcare insurance policy provides benefits to a resident requiring nursing home care and services?
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Long-term or extended care insurance
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Which of the following services has the highest likelihood of being a "covered service"?
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Medically necessary
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In the healthcare sector, when a patient's healthcare services are covered under a voluntary healthcare insurance plan, the person who pays the remainder of a healthcare bill, after the healthcare insurance company has paid, is called the guarantor.
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True
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Providers' reimbursement is faster and more accurate when they submit clean claims to third-party payers than when they submit dirty claims.
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True
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All of the following phenomena are typical exclusions found in insurance plan riders EXCEPT:
*Experimental therapeutic procedures *Emergency care under the prudent layperson standard *Medically unnecessary diagnostic procedures *Cosmetic procedures |
Emergency care under the prudent layperson standard
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A period of time that must pass before coverage for and employee or dependent who is otherwise eligible to enroll under the terms of a group health plan can become effective is called:
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Waiting period
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Which of the following is a limitation in insurance?
*Formulary *Write off *EOB *Carve outs |
Formulary
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The worker had group healthcare insurance coverage through her employer. The worker's household included her spouse, two natural children (ages 28 and 12), an adopted child (age 8), a 6-month infant in the waiting period prior to adoption, and the worker's mother (age 58). Who may be included under dependent coverage in the healthcare insurance policy?
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Spouse, natural child age 12, adopted child age 8m and 6-month infant in waiting period
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Which of the following is also known as a group plan?
*Private individual healthcare insurance plans *Blue Cross and Blue Shield *Medicare *Employer-based healthcare insurance plans |
Employer-based healthcare insurance plans
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Blue Cross and Blue Shield plans are all not for profit.
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False
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Which of the following characteristics is the greatest advantage of group healthcare insurance?
*Guaranteed issue *Greater benefits for lower premiums *Smaller risk pool *Higher out-of-pocket expenses |
Greater benefits for lower premiums
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All of the following phenomena are considered "life events" EXCEPT:
*Birth *Marriage *Adoption of a child *Illness |
Illness
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Co-insurance and co-payments are types of:
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Cost sharing
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The female worker was just married on July 1, 2016. She had worked for the organization for the past 8 years and has been covered under its group healthcare insurance policy during the entire period. She is ONLY allowed to add her new spouse during open enrollment which, for this organization, is October 1, 2016 through November 1, 2016 becoming effective on January 1, 2017.
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False
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The amount during a time-frame beyond which all covered healthcare services for an insured or dependent are paid 100 percent by the insurance plan is:
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The stop-loss benefit
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In the healthcare sector, what is the term for a group of individual entities, such as individual persons, employers, or associations, whose healthcare costs are combined for evaluating financial history and estimating future costs?
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Risk pool
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Potential moral hazards in consumer driven healthcare plans would be:
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Being an inpatient when being an outpatient would have had the same outcome
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All of the following data elements are on a remittance advice EXCEPT:
*Actual charge *Allowable charge *Claim attachment *Cost sharing |
Claim attachment
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In the healthcare industry, what is the term for the written report that insurers use to notify insureds about the extent of payments made on a claim?
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Explanation of Benefits
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Laws passed by many states that directed healthcare companies to base decisions to pay on symptoms at the time and not diagnosis after tests is called:
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Prudent layperson standard
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Out-of-pocket costs for subscribers and patients are decreasing.
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False
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Under a voluntary healthcare insurance plan, who pays the remainder of a healthcare bill after the insurance company pays?
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Guarantor
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Which type of healthcare insurance policy provides benefits to a homeowner who requires an 8-month recuperation after a fall down her basement stairs?
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Disability income protection insurance
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Which of the following characteristics is representative of commercial healthcare insurances?
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For-profit in the private sector
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