Healthcare Revenue Management Final Exam
170questions and answers 100%correctly Verified
2024/2025 RATED A+
Abuse - CORRECT ANSWERS Unknowing or unintentional submission of
an inaccurate claim for payment
Accountable Care Organization (ACO) - CORRECT ANSWERS population-
based model for healthcare delivery and payment
Accounts Receivable (AR) - CORRECT ANSWERS The amounts owed to a
facility by patients or insurance companies who receive services but whose
payments will be made at a later date.
Actual Charge - CORRECT ANSWERS The amount a physician or supplier
actually bills for a particular service or supply.
Adjudication - CORRECT ANSWERS (1) The determination of the
reimbursement amount based on the beneficiary's insurance plan benefits. (2) The
process by the payer of paying claims submitted or denying them after comparing
the claim to the benefit and coverage requirements.
Adjustment - CORRECT ANSWERS
Allowable charge - CORRECT ANSWERS amount the third-party payer or
insurance company will pay for a service
Ambulatory Payment Classification (APC) - CORRECT ANSWERS A
resource-based system used in the Medicare Hospital Outpatient Prospective
Payment System (OPPS). The APC system combines procedures and services that
are clinically comparable, with respect to resource use, into groups which are used
to determine reimbursement levels.
Ambulatory surgery center (ASC) - CORRECT ANSWERS Under Medicare,
an outpatient surgical facility that has its own national identifier; is a separate entity
with respect to its licensure, accreditation, governance, professional supervision,
administrative functions, clinical services, record keeping, and financial and
accounting systems; has as its sole purpose the provision of services in connection
,Healthcare Revenue Management Final Exam
170questions and answers 100%correctly Verified
2024/2025 RATED A+
with surgical procedures that do not require inpatient hospitalization; and meets the
conditions and requirements set forth in the Medicare Conditions of Participation
Appeal - CORRECT ANSWERS A request for a review of an insurance
claim that has been underpaid or denied by an insurance company in an effort to
receive additional payment.
Assignment of benefits - CORRECT ANSWERS Contract between a
physician and Medicare in which the physician agrees to bill Medicare directly for
covered services, to bill the beneficiary only for any coinsurance or deductible that
may be applicable and to accept the Medicare payment as a payment in full.
Medicare usually pays 80% of the approved amount directly to the provider of
services after the beneficiary meets the annual Part B deductible. The beneficiary
pays the other 20% (coinsurance).
Barcoding - CORRECT ANSWERS Tagging the packaging of each item with
a machine-readable Universal Product Code (UPC) to identify a medication
Benchmarking - CORRECT ANSWERS The process of comparing
performance with a preestablished standard or performance of another facility or
group.
Beneficiary - CORRECT ANSWERS An individual who is eligible for
benefits from a health plan
Benefit Period - CORRECT ANSWERS Length of time that a health
insurance policy will pay benefits for the member, family, and dependents.
Birthday rule - CORRECT ANSWERS The method of determining primary
coverage for a dependent child, under which the plan of the parent whose birthday
occurs first in the calendar year is designated as primary.
Bundling - CORRECT ANSWERS Occurs when payment for multiple
significant procedures or multiple units of the same procedure related to an
, Healthcare Revenue Management Final Exam
170questions and answers 100%correctly Verified
2024/2025 RATED A+
outpatient encounter or to an episode-of-care is combined into a single unit of
payment.
Capitation - CORRECT ANSWERS Method of payment for health services
in which an individual or institutional provider is paid a fixed, per capita amount for
a period.
Case management - CORRECT ANSWERS 1. A process used by a doctor,
nurse, or other health professional to manage a patient's healthcare (CMS 2013) 2.
The ongoing, concurrent review performed by clinical professionals to ensure the
necessity and effectiveness of the clinical services being provided to a patient
Case mix - CORRECT ANSWERS Set of categories of patients (type and
volume) treated by a healthcare organization and representing the complexity of
the organization's caseload.
Case Mix Index (CMI) - CORRECT ANSWERS Single number that compares
the overall complexity of the healthcare organization's patients with the complexity
of the average of all hospitals. Typically, the CMI is for a specific period and is
derived from the sum of all diagnosis-related group (DRG) weights divided by the
number of Medicare cases.
Case-rate methodology - CORRECT ANSWERS Type of prospective
payment method in which the third-party payer reimburses the provider a fixed,
preestablished payment for each case.
Centers for Medicare and Medicaid Services (CMS) - CORRECT ANSWERS
The department of Health and Human services agency responsible for Medicare and
parts of medicaid. Historically, CMS has maintained the UB-92 institutional EMC
format specifications, the professional EMC NSF specifications, and specifications for
various certifications and authorizations used by the Medicare and Medicaid
programs. CMS is responsible for the oversight of HIPPA administrative simplification
transaction and code sets, health identifiers, and security standards. CMS also
maintains the HCPCS medical code set and the Medicare Remittance Advice Remark
Codes administrative code set.
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