HCMT 2325 Chapter 10 Exam Questions with Latest Update
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AHIP abuse
Institution
AHIP Abuse
abuse - Answer-Pattern of practice that is inconsistent with sound business, fiscal, or health service practices, and that results in unnecessary costs to payers and government programs, reimbursement for services not medically necessary, or failure to meet professionally recognized standards for h...
HCMT 2325 Chapter 10 Exam Questions
with Latest Update
abuse - Answer-Pattern of practice that is inconsistent with sound business, fiscal, or
health service practices, and that results in unnecessary costs to payers and
government programs, reimbursement for services not medically necessary, or failure to
meet professionally recognized standards for health services.
capitation payment - Answer-A predetermined payment for each health plan enrollee.
case mix - Answer-the types and categories of patients treated by a health care facility
or provider.
case-mix adjustment - Answer-Multiple possible payment rates based on patients'
anticipated care needs that allow payment systems to decrease the average difference
between the pre-established payment and each patient's actual cost to the facility.
Case Mix Index (CMI) - Answer-The average relative weight of all cases treated at a
given facility or by a given physician, which reflects the resource intensity or clinical
severity of a specific group in relation to the other groups in the classification system;
calculated by dividing the sum of the weights of diagnosis-related groups for patients
discharged during a given period by the total number of patients discharged
chargemaster - Answer-Lists all the procedures, services and supplies provided to
patients by a hospital; charges for each may also appear.
check digit - Answer-A one-digit character, alphabetic or numeric, used to verify the
validity of a unique identifier.
Civil Monetary Penalties Act - Answer-Imposes a maximum penalty of up to $10,000
plus a maximum assessment of up to three times the amount claimed by providers who
knew that a procedure/service was not rendered as submitted on the claim; violators
can also be excluded from participation in government programs.
clearinghouse - Answer-A public or private entity (billing service, repricing company)
that processes or facilitates the processing of health information received from another
entity.
UB-04 (cms-1450) form - Answer-Standard institutional claim form submitted by
hospitals, skilled nursing facilities, and other institutional-based providers to payers to
obtain reimbursement for health care services provided to patients.
, CMS-1500 form - Answer-Universal claim form developed by the Centers for Medicare
& Medicaid Services (CMS) and used by providers (i.e., physicians) to bill payers for
professional fees and office procedures and services.
codes - Answer-Numeric and alphanumeric characters.
coding systems - Answer-Organizes a medical nomenclature according to similar
conditions, diseases, procedures and services, and established codes; also called
classification system.
compliance guidance - Answer-Guidelines that identify risk areas and offer concrete
suggestions to improve and enhance an organization's internal controls so that its billing
practices and other business arrangements are in compliance with Medicare's rules and
regulations.
Consumer-Directed Health Plan (CDHP) - Answer-Defines employer contributions and
asks employees to be more responsible for health care decisions and cost sharing;
includes customized sub-capitation plan (CSCP), flexible spending account (FSA),
health savings account (HSA), health savings security account (HSSA), health care
reimbursement account (HCRA), and health reimbursement arrangement (HRA).
copayment - Answer-A specified dollar amount to be paid to a health care provider for
each visit or medical service received.
critical pathways - Answer-Interdisciplinary guidelines developed by hospitals to
facilitate management and delivery of quality clinical care in a time of constrained
resources.
disability insurance - Answer-Replaces 40 - 60 percent of an individual's gross income
(tax free) if an illness or injury prevents the individual from earning an income; also
called disability income insurance.
Electronic Data Interchange (EDI) - Answer-Computer-to-computer transfer of data
between provider and payer (or clearinghouse) using a data format agreed upon by the
sending and receiving parties.
elimination period - Answer-A 90-day waiting period from onset of disability policies
usually require before the individual can apply for disability benefits.
False Claims Act (FCA) - Answer-Enacted in 1863 in response to widespread abuses
by government contractors during the Civil War and amended in 1986 to strengthen the
law and increase monetary awards (e.g., up to $11,000 per false claim, plus three times
the amount of damages that the government sustains). Imposes civil liability on those
who submit false/fraudulent claims to the government for payment and can exclude
violators from participation in government programs.
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