Complete Healthcare Reimbursement Q&A Bundle

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...

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...

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...

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 ...

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...

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...

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 ...

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...

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...

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...

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 ...

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...

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...

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...