Reimbursement in Healthcare Exam Questions and Correct Answers
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Course
Healthcare Reimbursement
Institution
Healthcare Reimbursement
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 ...
Reimbursement in Healthcare Exam
Questions and Correct Answers
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 government is the largest single payer and amount paid is not buy price but the
reimbursement rules & regulations set by laws
Fee-For-Service ✅The provider receives payment for each service provided to the
patient. Based on 'what was done' not 'what was wrong'. 3 types:
- Self pay
- Retrospective payment
- Managed care
Episode-of-care ✅Reimbursement is based on the patients' illness/condition or a
specific time period over which the patient receives care.
Ex: dialysis, surgery and post op visits) 3 types:
- Managed care - capitalization
- Global payment/ Prospective payment
- Prospective payment
Fee-For-Service : Self-pay ✅1. Self-pay (dollar for dollar)
2. Self-pay discount ( discount if bill I paid in full at visit)
3. Payer with Private insurance (patient pays bill to Doctor, itemized bill sent to insurer,
insurer reimburses patient, most of the cost)
Fee-For-Services : Retrospective Payment ✅Patient receives services and
reimbursement is based in past events. Payment is based on costs and charges
actually incurred for the care of the patient during the encounter.
Fee Schedules : Allowable Fees ✅Are a discounted fee-for-service system used by
man third-party payers to establish maximum reimbursement rates
Patient can be asked to pay the difference between bill and allowed fee, if the
agreement states this. Or, the provider writes off the balance.
Usual, Customary, Reasonable Reimbursement. (UCR) ✅Is the amount paid for a
medical service in a geographic are based on what providers in the area usually charge
, for the same or similar service. This is sometimes used to determine the allowed
amount. The balance may or may not be billed to the patient.
Resource-Based Relative Value Scale (RBRVS) ✅Used by Medicare to reimburse
physicians and particularly important in outpatient coding of physician care. Since
Medicare is Federal and State programs the fees vary from state to state. 1992 this was
based on 3 factors which create the "relative value unit" which is multiplied by a dollar
amount set by CMS.
- Physician's Work
- Practice Expense
- Professional Liabilty
RBRVS calculation ✅CPT code (procedure code fee determined by CMS) X RVU
(from CMS) = Fee for billing
RVU ✅Relative Value Unit. Fee for procedure set by CMS. Factors considered:
physician work, technical skill, physical and mental effort, judgment, stress, and
potential risk is involved in each procedure.
Managed Care ✅The third-party payer takes an active role in influencing cost and
quality through its policies and provisions. An example of managed care is pre-
authorization. This influences patient's decision by requiring a second opinion or
conservative therapy. They may limit length of hospital stay, too.
Managed Care under Retrospective payment ✅I a patient does not get a referral from
their primary physician and chooses to see a specialist they may have to pay out of
pocket.
HMO : Health Maintenance Organizations (retrospective model) ✅Most control over
patient choice. Structure includes a primary physician as gateway to services. Case
Managers are assigned to patients with certain illnesses to over see the services
provided and avoid duplicates, overlapping care etc.
HMO : Health Maintenance Organizations (fee-for-service model) ✅Most control over
patient choice. Structure includes a primary physician as gateway to services. Case
Managers are assigned to patients with certain illnesses to over see the services
provided and avoid duplicates, overlapping care etc. ** Both patient and. Physician must
follow guidelines set by third-party payer to receive maximum reimbursement.
PPO. : Perferred Provider Organizations ✅Third-party payer contracts with the Health
provider for discounted rates. If a patient elects to see one of these physicians in the
"network" the patient pays a smaller amount than for outside network physicians.
Fee-for-service summary ✅All fee-for-service reimbursement methodologies have a
few common elements:
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