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[Show more]Activities of daily living (ADL) Everyday tasks that people can perform without assistance and that are used to measure their functional status and, thus, their need for institutional or assisted care. 
Average length of stay (ALOS) Average number of days patients are hospitalized. 
Base rate 1. Rat...
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Add to cartActivities of daily living (ADL) Everyday tasks that people can perform without assistance and that are used to measure their functional status and, thus, their need for institutional or assisted care. 
Average length of stay (ALOS) Average number of days patients are hospitalized. 
Base rate 1. Rat...
Arithmetic Mean Length of Stay (AMLOS) Sum of all lengths of stay in a set of cases divided by the number of cases. 
Base Payment Rate 1) Rate per discharge for operating and capital-related components for an acute-care hospital. 2) Prospectively set payment rate made for services that Medicare bene...
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Add to cartArithmetic Mean Length of Stay (AMLOS) Sum of all lengths of stay in a set of cases divided by the number of cases. 
Base Payment Rate 1) Rate per discharge for operating and capital-related components for an acute-care hospital. 2) Prospectively set payment rate made for services that Medicare bene...
Health Care Financing Administration Created in 1977 to coordinate and administer Medicare and Medicaid 
HIPPA provisions 1. Ensures coverage for preexisting conditions 2. Protects against discrimination based on health status 3. Right to purchase individual plan 
Healthy People 2000 objectives 1. H...
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Add to cartHealth Care Financing Administration Created in 1977 to coordinate and administer Medicare and Medicaid 
HIPPA provisions 1. Ensures coverage for preexisting conditions 2. Protects against discrimination based on health status 3. Right to purchase individual plan 
Healthy People 2000 objectives 1. H...
In which type of healthcare payment method, does the healthcare plan recompense providers each month with a set amount of money for each individual enrolled in the healthcare plan? Capitated rate 
In which type of healthcare payment method does the healthcare plan pay for each service that a provide...
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Add to cartIn which type of healthcare payment method, does the healthcare plan recompense providers each month with a set amount of money for each individual enrolled in the healthcare plan? Capitated rate 
In which type of healthcare payment method does the healthcare plan pay for each service that a provide...
ICD-10-CM The coding system that is used primarily for reporting diagnoses for hospital inpatients 
CPT coding systems created for reporting procedures and services performed by physicians in clinical practice? 
WHO ICD is maintained by 
lessons learned from RAC demonstration -RACs are able to find ...
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Add to cartICD-10-CM The coding system that is used primarily for reporting diagnoses for hospital inpatients 
CPT coding systems created for reporting procedures and services performed by physicians in clinical practice? 
WHO ICD is maintained by 
lessons learned from RAC demonstration -RACs are able to find ...
There are 3 parties in healthcare reimbursement. Who is the second party? Provider of care or services 
All of the following methods are types of episode-of-care reimbursement EXCEPT: Self-insured plan 
Which of the three models for health systems predominates in the United States? Private health in...
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Add to cartThere are 3 parties in healthcare reimbursement. Who is the second party? Provider of care or services 
All of the following methods are types of episode-of-care reimbursement EXCEPT: Self-insured plan 
Which of the three models for health systems predominates in the United States? Private health in...
What are the two types of reimbursement systems Fee-for-service and episode-of-care 
fee-for-service a system under which doctors and hospitals receive a payment for each service they provide 
Episode-of care Payment based on services provided for conditions for which the patient is treated. 
3 exam...
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Add to cartWhat are the two types of reimbursement systems Fee-for-service and episode-of-care 
fee-for-service a system under which doctors and hospitals receive a payment for each service they provide 
Episode-of care Payment based on services provided for conditions for which the patient is treated. 
3 exam...
HIPAA (Health Insurance Portability and Accountability Act) Designated the code sets for healthcare services reporting to public and private insurers. 
HITSP (Health Information Technology Standards Panel) identified standards for the electronic exchange of health information 
NCHS (National Center ...
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Add to cartHIPAA (Health Insurance Portability and Accountability Act) Designated the code sets for healthcare services reporting to public and private insurers. 
HITSP (Health Information Technology Standards Panel) identified standards for the electronic exchange of health information 
NCHS (National Center ...
AHA CODING CLINIC FOR HCPCSAHA CODING CLINIC FOR ICD-10-CM & ICD-10 PCS A publication issued quarterly by the American Hospital Association & approved by the Centers for MC & MK Services (CMS) to give coding advice & direction for International Classification of Diseases, 10th Revision, Clinical Mod...
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Add to cartAHA CODING CLINIC FOR HCPCSAHA CODING CLINIC FOR ICD-10-CM & ICD-10 PCS A publication issued quarterly by the American Hospital Association & approved by the Centers for MC & MK Services (CMS) to give coding advice & direction for International Classification of Diseases, 10th Revision, Clinical Mod...
Balance billing Allowing the provider to charge the patient the difference of the allowed amount from insurance 
Allowed charge The allowable charge, or payment set by the health care plan for each covered service. This is the maximum fee the health plan will pay for that service or procedure. 
What...
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Add to cartBalance billing Allowing the provider to charge the patient the difference of the allowed amount from insurance 
Allowed charge The allowable charge, or payment set by the health care plan for each covered service. This is the maximum fee the health plan will pay for that service or procedure. 
What...
Healthcare reimbursement methodologies breakdown into two primary types: 1- Fee-For-Service, Reimbursement based on: •Services provided to the patient 1.Self-pay 2.Retrospective payment 3.Managed care 
2. Episode-of-Care, Patient's condition/illness •A specified time period 1.Managed care - cap...
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Add to cartHealthcare reimbursement methodologies breakdown into two primary types: 1- Fee-For-Service, Reimbursement based on: •Services provided to the patient 1.Self-pay 2.Retrospective payment 3.Managed care 
2. Episode-of-Care, Patient's condition/illness •A specified time period 1.Managed care - cap...
Episode-of-Care determine payment based on one lump sum payment for all the care provided related to a disease or particular condition. (time factor) - unit of time may be daily, monthly, or other specific time period 
Managed Care- Capitation Reimbursement method - third-party payer contracts with ...
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Add to cartEpisode-of-Care determine payment based on one lump sum payment for all the care provided related to a disease or particular condition. (time factor) - unit of time may be daily, monthly, or other specific time period 
Managed Care- Capitation Reimbursement method - third-party payer contracts with ...
In this healthcare delivery model, the government is the only payer that funds universal healthcare coverage through taxes NATIONAL INSURANCE MODEL 
In this healthcare delivery model, the insurance company determines that contribution amount that is not based on the policyholder's income PRIVATE IN...
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Add to cartIn this healthcare delivery model, the government is the only payer that funds universal healthcare coverage through taxes NATIONAL INSURANCE MODEL 
In this healthcare delivery model, the insurance company determines that contribution amount that is not based on the policyholder's income PRIVATE IN...
What is the name of your state's insurance commission? Bureau of Insurance 
What is the mission of your state's insurance commission? to ensure that citizens of the Commonwealth are provided with access to adequate and reliable insurance protection; that the insurance companies selling policies ar...
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Add to cartWhat is the name of your state's insurance commission? Bureau of Insurance 
What is the mission of your state's insurance commission? to ensure that citizens of the Commonwealth are provided with access to adequate and reliable insurance protection; that the insurance companies selling policies ar...
Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to calculate the group's premiums? To assure that the pool is large enough to pay losses of the entire group 
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for...
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Add to cartWhy do health insurers pool premium payments for all the insureds in a group and use actuarial data to calculate the group's premiums? To assure that the pool is large enough to pay losses of the entire group 
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for...
What is the difference between retrospective and prospective reimbursement? Retrospective reimbursement is based on the actual resources expended to deliver the services and is finalized after the services are delivered. Prospective reimbursement is established prior to the healthcare delivery and d...
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Add to cartWhat is the difference between retrospective and prospective reimbursement? Retrospective reimbursement is based on the actual resources expended to deliver the services and is finalized after the services are delivered. Prospective reimbursement is established prior to the healthcare delivery and d...
The US healthcare system is inherently complex because it is actually multiple subsystems rather than a single system 
Insurance a system of reducing a person's exposure to risk of loss by having another party (insurance company or insurer) assumes the risk 
Risk pool group of persons with similar ...
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Add to cartThe US healthcare system is inherently complex because it is actually multiple subsystems rather than a single system 
Insurance a system of reducing a person's exposure to risk of loss by having another party (insurance company or insurer) assumes the risk 
Risk pool group of persons with similar ...
Prospective payment system reimbursement methodology that establishes predetermined rates based on patient category or type of facility 
Prospective cost-based rates healthcare costs from which a prospective per diem rate is determined - this method may be based on case-mix 
Prospective price-based ...
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Add to cartProspective payment system reimbursement methodology that establishes predetermined rates based on patient category or type of facility 
Prospective cost-based rates healthcare costs from which a prospective per diem rate is determined - this method may be based on case-mix 
Prospective price-based ...
Why is Healthcare reimbursement different from other industries? 1. Patients often is not the person who pays 2. Complex contractual relationships between, patient, government, third-party payer, & provider 3. The dollar amount collected by the provider may vary widely depending on who pays 4. The g...
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Add to cartWhy is Healthcare reimbursement different from other industries? 1. Patients often is not the person who pays 2. Complex contractual relationships between, patient, government, third-party payer, & provider 3. The dollar amount collected by the provider may vary widely depending on who pays 4. The g...
Actual charge Amount provider actually bills a patient, which may differ from the allowable charge. 
Adjudication The determination of the reimbursement payment based on the member's insurance benefits. 
Adjustment Amount that healthcare insurers deduct providers' payments per contracted discounts...
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Add to cartActual charge Amount provider actually bills a patient, which may differ from the allowable charge. 
Adjudication The determination of the reimbursement payment based on the member's insurance benefits. 
Adjustment Amount that healthcare insurers deduct providers' payments per contracted discounts...
Capitation Method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount for each person enrolled without regard to the actual number or nature of services provided or number of persons served. 
Carve-out Contracts that separate out service...
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Add to cartCapitation Method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount for each person enrolled without regard to the actual number or nature of services provided or number of persons served. 
Carve-out Contracts that separate out service...
Payer System The United States has a first-party and third-party payment system: 
first-party = patient third-party = other entity 
Other Entity: - Government (Medicare/Medicaid) - Group/Individual Insurers - Industrial/Worker's Comp - Automobile Insurers - Liability Insurers - Charitable Organizat...
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Add to cartPayer System The United States has a first-party and third-party payment system: 
first-party = patient third-party = other entity 
Other Entity: - Government (Medicare/Medicaid) - Group/Individual Insurers - Industrial/Worker's Comp - Automobile Insurers - Liability Insurers - Charitable Organizat...
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