Health Care Reimbursement

Front 1

Prescription drugs would be paid by:

Back 1

Medicare Part D

Front 2

Inpatient hospitalization would be paid by:

Back 2

Medicare Part A

Front 3

In states where there is not a mandated fund for workers' compensation, what is an option for employers?

Back 3

*Purchase workers' compensation insurance from a private carrier

*Provide workers' compensation self-insurance coverage

Front 4

In which TRICARE program do ADFMs have a deductible and 20% copay?

Back 4

TRICARE Standard Network

Front 5

Which government-sponsored program provides coverage for the dependents of active members of the armed forces (ADFM)?

Back 5

TRICARE

Front 6

True/False

CHAMPVA is a primary payer unless other health insurance benefits are available.

Back 6

True

Front 7

The role of worker's compensation is to:

Back 7

Cover healthcare costs and lost income from a work related injury

Front 8

Medicare part C is a _________ option known as Medicare Advantage.

Back 8

Managed care

Front 9

What is true of CHIP?

Back 9

*It is a federal/state program

*It varies from state to state

Front 10

Which of the following is NOT a function of the Indian Health Service (IHS)?

*Assists Indian tribes in the development of their own health programs

*Facilitates and assists Indian tribes in coordinating health planning

*Provides only inpatient healthcare services

*Promotes using health resources available at federal state and local levels

Back 10

Provides only inpatient healthcare services

Front 11

In which of the following TRICARE plans are members entitled to Medicare part A and required to participate in Medicare part B?

*TRICARE standard

* TRICARE for Life

*TRICARE Extra

*TRICARE Prime

Back 11

TRICARE for Life

Front 12

What act authorized federal funds for Indian Health Services?

Back 12

Snyder Act of 1921

Front 13

A physician's office visit would be paid by:

Back 13

Medicare Part B

Front 14

ADSM's who live and work within 50 miles or less that an hour's drive of a military treatment facility are required to have:

Back 14

TRICARE Prime

Front 15

A program which provides states with grant money designated to provide low income families with case assistance is:

Back 15

TANF

Front 16

A child of a veteran who is permanently and totally disabled due to a service-connected disability can get:

Back 16

CHAMPVA

Front 17

All of the following are true of state Medicaid programs EXCEPT:

*Federal funds allocated to each state are based on the average income per person for that state

*The program must cover infants born to Medicaid-eligible pregnant women

*States may offer a managed care option

*Services offered to beneficiaries are the same in each state

Back 17

Services offered to beneficiaries are the same in each state

Front 18

Children can get Medicare if they have:

Back 18

End-stage renal disease

Front 19

Families whose income is too high to quality for Medicaid, but too low to afford private insurance can get ____________ for their children.

Back 19

CHIP

Front 20

Which Part of the Medicare program does not include a cost-sharing provision?

*Part A

*Part B

*Part C

*Part D

*All parts of Medicare include a cost-sharing provision

Back 20

All parts of Medicare include a cost-sharing provision

Front 21

Part A

Back 21

Inpatient hospital services

Front 22

Part B

Back 22

supplemental medical insurance

Front 23

Part C

Back 23

Medicare Advantage

Front 24

Part D

Back 24

Medicare Drug Benefit

Front 25

How does a Medicare beneficiary benefit by choosing Medicare Part C?

Back 25

It covers services excluded from Part A and Part B: Long term nursing care, Custodial care, Dental services, Vision services, Routine examinations, except initial preventive medicine examination added by MMA Health and wellness education, Acupuncture

Front 26

What types of costs do Medigap policies cover?

Back 26

Medigap covers most cost sharing expenses, (deductibles, coinsurance's, and copay's) and must meet federal standards and are offered by various private insurance companies.

Front 27

How does the ACA affect the market basket used to update Medicare reimbursement rates?

Back 27

The ACA is reducing the market basket with scheduled reductions and multi-factor productivity reductions.

Front 28

Why is Medicaid coverage not identical in New Jersey, California, and Idaho?

Back 28

Medicaid coverage is not identical in every state because coverage determination for services is state-specific. Eligibility and services may be expanded by individual states based on that state's laws and regulations.

Front 29

TRICARE program - ADFMs with deductible and 15 percent copay

Back 29

TRICARE standard netword

Front 30

TRICARE program -ADFMs with deductible and 20 percent cost-share

Back 30

TRICARE for ADSMs, Extra Nonnetwork

Front 31

TRICARE program - Managed care

Back 31

TRICARE Prime

Front 32

TRICARE program - Secondary coverage for Medicare beneficiaries

Back 32

TRICARE for life (TFL)

Front 33

True/False

When a CHAMPVA beneficiary reaches age 65, Medicare becomes the primary payer, and CHAMPVA becomes the secondary payer.

Back 33

True

Front 34

Services offered by the IHS to Indian tribes include all the following except:

*Rehabilitative services

*Death benefits

*Outpatient care

*Development of sanitation facilities

Back 34

Death benefits

Front 35

Why was the PACE program created?

Back 35

PACE is a joint Medicare-Medicaid venture that offers states the option of creating and administering this capitated managed care option for the frail elderly population.

Front 36

Which type of program is CHIP?

Back 36

Federal-State

Front 37

Which program replaced Aid to Families with Dependent Children (AFDC)?

Back 37

Temporary Assistance for Needy Families Program (TANF)

Front 38

What recent legislation made a substantive change to Medicare benefits, and how did those benefits change?

Back 38

*Medicare Modernization Act of 2003 (MMA) created an outpatient prescription drug benefit (Medicare Part D)

*Affordable Care Act (ACA) - lowering payments to healthcare providers

Front 39

List at least three types of Medicaid recipients required for states to qualify for federal matching funds.

Back 39

*Infants born to Medicaid eligible pregnant women

*Children younger than 6 whose family income is at or below the poverty level

*Adoption assistance or foster care recipients

Front 40

How was the PACE venture designed to enhance the quality of life for the frail elderly population?

Back 40

PACE was designed to enhance the quality of life for the frail elderly population by enabling them to live in their own homes and communities and to preserve and support their family units.

Front 41

What is the target population of the State Children's Health Insurance Program (CHIP) (Title XXI)?

Back 41

The target is children not covered by health insurance. It is designed to provide health insurance to children of families whose income level is too high to qualify for Medicaid but too low to afford private healthcare insurance. To qualify for the program, the child must reside with a family whose income is at or below a specified percent of the federal poverty level.

Front 42

Which TRICARE program is the most economical program for military families, and why is it less expensive than the other options?

Back 42

*Tricare Prime - it is managed care

*why- because this managed care program has no enrollment, deductible, or co-payment fees

Front 43

What program covers healthcare costs and lost income from work-related injuries or illness of federal government employees?

Back 43

Federal Employees' Compensations Act (FECA)

Front 44

True/False

Individuals eligible for railroad retirement disability or retirement benefits are ineligible for Medicare?

Back 44

False

Front 45

True/False

Individuals who are eligible may choose between TRICARE benefits and CHAMPVA.

Back 45

False

Front 46

True/False

In states having no mandated workers' compensation fund, employers must purchase insurance from private carriers or provide self-insurance coverage.

Back 46

True

Front 47

Who are "dual eligible's"?

Back 47

Individuals who are eligible for Medicare and Medicaid

Front 48

What is the term for an MCO that serves Medicare beneficiaries?

Back 48

Medicare Advantage

Front 49

In which type of HMO are the physicians employees?

Back 49

Staff model

Front 50

If members of a PPO use out-of-network providers, their out-of-pocket expenses are:

Back 50

Higher

Front 51

All of the following are elements of prescription management:

Back 51

*Formulary *Patient education *Alerts for interactions

Front 52

Evidence-based clinical guidelines originate from the following sources:

Back 52

*Agency for Healthcare Research and Quality *Centers for Disease Control and Prevention *American College of Cardiology

Front 53

A patient, who was a Medicaid recipient, asked about the types of financial incentives that the MCO used. What should the MCO's administrator do?

Back 53

Release summaries of the financial incentives

Front 54

True/False

Disease management is closely associated with coordination of care tools of MCOs because efforts of multiple providers must be synchronized in disease management.

Back 54

True

Front 55

What is meant by the phrase "point-of-service" in "point-of-service healthcare insurance plan"?

Back 55

Members choose the reimbursement model when they need healthcare services rather than during the open enrollment period

Front 56

All of the following services are typically reviewed for medical necessity and utilization EXCEPT: *Rehabilitative therapies *Inpatient admissions *Well-baby check *Mental health and chemical dependency care

Back 56

Well-baby check

Front 57

Of the following types of HMO's, which type is the most controlled? *Preferred provider organization *Staff model *Group practice model *Network model

Back 57

Staff model

Front 58

Contracts that separate out services or populations of patients to decrease risks and costs are:

Back 58

Carve outs

Front 59

What term means a network of organizations that directly provides or arranges to provide a coordinated continuum of services to a defined population and takes accountability for the cost, quality, and outcomes of care?

Back 59

Integrated delivery system

Front 60

Today's managed care traces its origins to all of the following arrangements EXCEPT:

*1800, Congress awarding pensions for U.S. naval personnel on the basis of death or disability during active service

*1906, Wester Clinic of Tacoma, Washington offering its members medical services for $0.50 per month

*1929, Blue Cross of Dallas, Texas establishing schoolteachers' plan of 21 days of hospitalization for $6 per year

*1930s, Kaiser construction setting up health plan for its workers

Back 60

1800, Congress awarding pensions for U.S. naval personnel on the basis of death or disability during active service

Front 61

The patient belonged to a managed care plan. Prior approval for the surgery was received. What number should the insurance analyst record?

Back 61

Precertification

Front 62

Targeting the enrollment of healthy patients to minimize healthcare costs is:

Back 62

Cherry picking

Front 63

For what reasons do MCOs survey their members for feedback?

Back 63

*To determine their satisfaction with services *To obtain their perceptions of the plan's strengths and weaknesses and their suggestions for improvements

*To learn their intentions regarding re-enrolling in the plan

Front 64

A member had gastric bypass surgery three years previously. As a result of losing more than 200 pounds, loose skin hung from the member's arms, thighs, and belly. The member upon referral from her general surgeon, was scheduled to have a plastic surgeon remove the excess skin. The member called for prior approval as required by the plan. The clinical review resulted in a denial of the surgery as cosmetic. The member requested a peer review and submitted documentation from her physician that the excess skin was causing skin infections and exacerbating her eczema. The peer clinician denied the case. What is the member's next step if she is determined to have the surgery?

Back 64

Appeal to an expert clinician in the same specialty

Front 65

All of the following types of organizations represent ways of integrating health organizations EXCEPT:

*Group practice without walls

*Solo physician practice

*Management service organization

*Medical foundation

Back 65

Solo physician practice

Front 66

All of the following activities are steps in medical necessity and utilization review EXCEPT:

*Initial clinical review

*Peer clinical review

*Appeal consideration *

Administrative review

Back 66

Administrative review

Front 67

For what type of care should the physician practice manager expect to work with a case manager?

Back 67

Workers' compensation

Front 68

All of the following activities are service management tools used in controlling costs EXCEPT:

*Applying an episode-of-care payment system *Determining medical necessity and utilization review

*Assigning the primary care provider as gatekeeper to specialized services through referrals and prior authorizations

*Case and prescription management

Back 68

Applying an episode-of-care payment system

Front 69

In a group practice, the physicians have maintained their separate practices and offices. The individual practices share administrative systems to form a group practice. Which form of integrated delivery system does this arrangement represent?

Back 69

Clinic without walls

Front 70

Access to mental or behavioral health or medical specialists is through referral. What is the term for the individual who makes the referral?

Back 70

Primary care provider, Gatekeeper, Primary care physician

Front 71

Which of the following activities do MCOs use as financial incentives to control costs? *Monitoring the settings of care *Rewarding providers who meet targets with bonuses *Varying members' rates of cost-sharing *All of the above

Back 71

All of the above

Front 72

List three types of care delivered by MCOs:

Back 72

HMO's, PPO's, POS's, preventive, wellness oriented, acute and chronic

Front 73

How does a member of a staff model HMO obtain coverage for a specialist, such as an oncologist?

Back 73

Primary care physicians strictly control referrals to specialists with in the HMO.

Front 74

In terms of the health population, what type of program, supported by MCOs, stresses the habits of healthy lifestyles, such as exercise and proper nutrition?

Back 74

Wellness programs

Front 75

What types of physicians are generally considered primary care physicians?

Back 75

family practitioners, general practitioners, internists, pediatricians, and OB/GYNs

Front 76

List at least three sources of evidence-based clinical practice guidelines.

Back 76

*The US Preventive Services Task Force (USPSTF)

*The Agency for Healthcare Research and Quality (AHRQ)

*The Centers for Disease Control and Prevention

Front 77

For what are integrated delivery systems willing to be held accountable?

Back 77

for the cost, quality, and outcomes of care and, (with others), the health status of the population served

Front 78

True/False

For integrated delivery systems, process integration is more important than functional integration.

Back 78

True

Front 79

Name two ways that practices having integrated structures lower their overhead costs.

Back 79

*Share centralized administrative systems *bargaining power in the negotiation of managed care contracts

Front 80

In which type of integrated delivery system do the physicians maintain their separate clinics, but share their administrative systems?

Back 80

Group (Practice) without Walls

Front 81

With which type of integrated delivery system would a small group practice contract for administrative and information systems?

Back 81

Management Service Organization

Front 82

Describe at least three ways in which MCOs work toward their goals of quality patient care.

Back 82

*Careful selection of provider

*Emphasis on the health of their populations of members

*Use of care management tools, and maintenance of accreditation or participation in quality improvement programs

Front 83

From where do evidence-based clinical guidelines originate?

Back 83

They have been systematically developed from scientific evidence and clinical expertise to answer clinical questions. These guidelines are benchmarks of best practices in the care and treatment of patients and clients.

Front 84

List at least two reasons that MCOs survey their members for feedback.

Back 84

-Perceptions of the plan's strengths and weaknesses

-Suggestions for improvements

Front 85

Name the three steps in medical necessity and utilization review.

Back 85

*Initial Clinical Review

*Peer Clinical Review

*Appeals Consideration

Front 86

Describe three types of cost controls used by MCOs.

Back 86

*Service Management Tools include medical necessity and utilization management, the gatekeeper role of the primary care provider, prior approval, second and third opinions, case management, and prescription management.

*Episode of care reimbursement includes capitation and global payment.

*Financial Incentives include providers meeting fiscal targets and members using providers connected to the plan.

Front 87

Which type of HMO offers patients the least selection in referrals to specialists?

Back 87

Staff Model

Front 88

List at least five types of services or populations that are common examples of carve-outs.

Back 88

*Chronically ill children

*Dental care

*Diseases or conditions

*Prescription drug (pharmacy benefit)

*Specialty services

*Vision Care

Front 89

True/False

Disease management is closely associated with coordination of care tools of MCOs because efforts of multiple providers must be synchronized in disease management.

Back 89

True

Front 90

True/False

By definition, integrated delivery systems must directly provide health services to their members.

Back 90

False

Front 91

True/False

Integrated delivery systems, as a result of strict federal regulation, have evolved into a single common type.

Back 91

False

Front 92

Discuss two of the four guiding principles of prospective payment.

Back 92

Payment rates are to be established in advance and fixed for the fiscal period to which they apply.

Payment rates are not automatically determined by the hospital's past or current actual cost.

Front 93

In the four-step MS-DRG assignment process, if a coder is able to assign the MS-DRG in step 1, the pre-MDC assignment, all subsequent steps in the process are ___________.

Back 93

ignored

Front 94

List two refinement questions that help coders group together patients with like-resource consumption.

Back 94

Is a major complication or co-morbidity (MCC) present?

Is a complication or co-morbidity (CC) present?

Front 95

How are Medicare base payment rates increased to reflect inflation?

Back 95

The base year amount has been updated each year since 1981 by the market basket, an update factor established by Congress to account for inflation.

Front 96

How is the discharge disposition used in the execution of PACT payment?

Back 96

The discharge disposition identifies where the patient goes for care after discharge. There are 2 types of transfer cases under the IPPS and payment to each hospital is based on a type 1 or a type 2 transfer. Exceptions to the payment policy, known as the post-acute-care-transfer (PACT) policy, for type 2 transfer cases is for certain MS-DRG's that qualify for the PACT policy, a discharge from an acute IPPS hospital to an excluded IPPS hospital or unit is considered a type 1 transfer rather than a discharge. The PACT transfer policy ensures that an incentive is not created for hospitals to discharge any patients early to reduce costs while sill receiving full MS-DRG payment.

Front 97

Which piece of legislation charged CMS with creating a PPS for the inpatient psychiatric setting? What requirements were included in the law?

Back 97

The Balanced Budget Refinement Act (BBRA) of 1999. Required the development of a per diem PPS for inpatient psychiatric services provided in IPFs (inpatient Psychiatric Facilities). Specifically, the BBRA charged CMS with developing a classification system that would reflect the resource consumption and, thus, cost differences among various IPFs.

Front 98

What type of reimbursement scheme is used in the IPF PPS?

Back 98

Per diem with adjustments

Front 99

What is the formula for the ECT adjustment for a facility with a wage index of .9812?

Back 99

Step 1. federal per diem base rate x labor percent x wage index amount

Step 2. federal per diem base rate x non-labor percent

Step 3. the sum of the results of steps 1 and 2 = the wage index adjusted per diem amount

Front 100

What are the two categories of adjustments in the IPF PPS?

Back 100

patient level adjustments and facility level adjustments

Front 101

List and discuss two of the provisions of the IPF PPS.

Back 101

Outlier payment for high-cost encounters. Outlier payments are projected by CMS to account for 2 percent of the total payment for the implementation year. The costs of an encounter must exceed the adjusted threshold amount to qualify for an outlier payment.

Medical Necessity Provision - must be established for each patient on admission to the IPF.

Front 102

List at least two major reasons why Medicare administrators turned to the prospective payment concept for Medicare beneficiaries.

Back 102

Medicare payments to hospitals grew, on average, by 19% annually (3 times the average overall rate of inflation).

The Medicare hospital deductible expanded, creating a burden for Medicare beneficiaries.

Front 103

How do MS-DRGs encourage inpatient facilities to practice cost management?

Back 103

The hospital retains the profit or suffers a loss resulting from the difference between the payment rate and the hospital's cost, creating an incentive for cost control.

Front 104

Why was a severity of illness refinement performed on the DRG system? Was it supported by the healthcare community?

Back 104

The severity of illness refinement allows cases with a higher severity of illness to be paid appropriately. Yes, the healthcare community supported it.

Front 105

List the steps of MS-DRG assignment.

Back 105

1. Pre-MDC Assignment

2. MDC Determination

3. Medical/Surgical Determination

4. Refinement

Front 106

Why does the IPF PPS length-of-stay adjustment factor grow smaller during the patient encounter?

Back 106

The length-of-stay adjustment was implemented because data showed that per-diem costs for psychiatric cases decreases as LOS increases.

Front 107

Describe at least two patient-level adjustments for IPF PPS claims and explain why they are used.

Back 107

Comorbid Conditions - cost data identifies a need to provide a payment adjustment for some comorbid conditions.

Older Patients - rates are altered to account for the additional costs incurred for treating older patients.

Front 108

What is the labor portion of the IPF PPS per diem rate?

What is the non-labor portion of the IPF PPS per diem rate?

Back 108

The labor portion of the federal per diem base rate is 69.294%.

The non-labor portion is the federal per diem rate is 30.706%.

Front 109

Why was the initial stay and readmission provision included in the IPF PPS?

Back 109

CMS did not want to provide an incentive for facilities to prematurely discharge patients and then subsequently re-admit them because the length of stay adjustment is weighted heavier for the beginning days for an admission.

Front 110

Describe the medical necessity provision of the IPF PPS.

Back 110

Medical necessity must be established by the physician at the start of the inpatient psychiatric admission. Medical necessity must be re-evaluated and established for admissions that extend past the 18th day.

Front 111

When performing the payment determination for IPF PPS admissions, which step comes first: wage-index adjustment, or application of the patient and facility-level adjustments?

Back 111

wage index adjustment

Front 112

Medical necessity must be re-evaluated and established in the IPF PPS for admissions that extend past the ______ day.

Back 112

18th

Front 113

Mary Smith was admitted to IPF Hospital A on April 1. She is discharged on April 5. Mary Smith is readmitted to IPF Hospital B on April 7 and continues the hospital stay until April 10. What length-of-stay adjustment day should be used to calculate the payment for the first day payment for IPF Hospital B?

Back 113

Day 5

Front 114

Mr. Brown was admitted to the hospital with severe chest pains. During his encounter he underwent a coronary artery bypass procedure (CABG) due to coronary artery disease (CAD). What is the first step in determining the MS-DRG assignment for this encounter?

Back 114

Determine if the coronary artery bypass procedure is one of the Pre-MDC procedures

Front 115

A Medicare patient was discharged from one acute IPPS and admitted to another acute IPPS hospital on the same day. How will the two acute IPPS hospitals be reimbursed?

Back 115

The first hospital receives a per-diem payment derived from the potential MS-DRG and the second hospital receives the full MS-DRG.

Front 116

What concept is a guiding principle for prospective payment?

Back 116

Payment rates are established in advance of the healthcare delivery and are fixed for the fiscal period to which they apply.

Front 117

What is the average of the sum of the relative weights of all patients treated during a specified time period?

Back 117

Case mix index

Front 118

Which of the following IPPS provisions provides the hospital with a hospital specific reimbursement amount?

*Indirect medical education

*High cost outlier cases

*New medical services and new technology

* A & B

*B & C

Back 118

A & B

Front 119

Which of the following is NOT a patient level adjustment used in the IPF PPS?

*Length of stay

*Comorbidity

*MS-DRG

*Full service emergency department

Back 119

Full service emergency department

Front 120

Which piece of legislation called for the first hospital inpatient prospective payment system? This piece of legislation also allowed some hospital setting to retain their cost-based payment systems.

Back 120

Tax Equity and Fiscal Responsibility Act (TEFRA)

Front 121

Which of the following is not a facility-level adjustment under the IPF PPS?

*Wage index

*Electroconvulsive therapy

*Rural location

*Cost-of-living adjustment

Back 121

Electroconvulsive therapy

Front 122

Which IPPS provision is provided to facilities that experience a financial hardship because they provide treatment for patients who are unable to pay for the services?

Back 122

Disproportionate share hospital

Front 123

True/False

If a coder is able to assign the MS-DRG in the pre-MDC assignment step, all other steps are ignored.

Back 123

True

Front 124

True/False

Data showed that per-diem costs for psychiatric cases increases as length of stay increases.

Back 124

False

Front 125

Which Medicare contractor reimburses acute care hospitals on behalf of Medicare?

Back 125

Medicare administrative contractor (MAC)

Front 126

Within the IPF PPS which of the following statements is true?

*The cost for psychiatric cases decreases as the length of stay increases

*Electroconvulsive therapy is provided for every patient

*It is less expensive to treat a 75 year old patient than a 55 year old patient

*All of the above are false

Back 126

The cost for psychiatric cases decreases as the length of stay increases

Front 127

Under the IPF PPS which states are included in the cost of living adjustment (COLA)?

Back 127

Hawaii and Alaska

Front 128

The MS-DRG payment includes reimbursement for all of the following inpatient services except:

*Physician hospital visit

*Surgery

*Laboratory tests

*Medications

Back 128

Physician hospital visit

Front 129

Computer programs that assign patients to case mix groups are called:

Back 129

Groupers

Front 130

The MS-DRG payment includes reimbursement for all of the following inpatient services EXCEPT:

*Medications

*Progress notes

*Laboratory tests

*Dressings and other supplies

Back 130

Progress notes

Front 131

What is the basis of the "labor-related share"?

Back 131

Facilities' costs related to payrolls, benefits, and professional fees

Front 132

In the IPPS, what is the term for each hospital's unique standardized amount based on its cost per Medicare discharge?

Back 132

Base payment rate

Front 133

When comparing Medicare's IPPS and IPF PPS which of the following statement is false?

*Both PPS use wage index adjustments to account for differences in the cost of labor

*Both PPS have a high cost outlier provision

*Both PPS utilize a case rate reimbursement methodology

*Although different, both PPS provide supplemental reimbursement for physician education programs

Back 133

Both PPS utilize a case rate reimbursement methodology

Front 134

What IS the correct order for MS-DRG assignment?

Back 134

Pre MDC assignment, MDC determination, Medical/Surgical determination, Refinement

Front 135

Which reimbursement methodology is used in the Inpatient Psychiatric Facility Prospective Payment System?

Back 135

Per diem rate

Front 136

What act required the development of a per diem PPS for inpatient psychiatric services provided in IPFs?

Back 136

Balanced Budget Refinement Act of 1999