Final exam Health & Reimb
questions and answers with
solutions.
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis.
Surgery for spinal fusion was cancelled after the patient was diagnosed with
mononucleosis. On today's visit the patient is started on prednisone for severe
sore throat and difficulty swallowing. The patient was accompanied by his parents
who have health insurance through the mother's employment at the State
Department of Treasury. Who is the first party in this healthcare reimbursement
scenario? - Answer Parents
An employee paying for 40 percent of the insurance premium through payroll
processing is an example of a transaction between ________ and ________. -
Answer Patient; employer
The national unadjusted payment amount is the product of the conversion factor
multiplied by the relative weight, unadjusted for __________. - Answer
Geographic factors
CMS has increased the weight for MS-DRG A by 14 percent, increased the weight
for MS-DRG B by 20 percent, and decreased the weight for MS-DRG D by 10
,percent. Given these new weights, which MS-DRG generated the most revenue
for Venice Bay Health Center? - Answer MS-DRG C
The MS-DRG that generated the most revenue for Venice Bay Health Center
is:Community Hospital collected the data displayed below concerning its four
highest volume MS-DRGs. - Answer MS-DRG C
Memorial Hospital's TOP 10 MS-DRGs
The case-mix index for the top 10 MS-DRGs above is: - Answer 1.2846
Which individual MS-DRG has the highest reimbursement? - Answer 247
SMI calculation is similar to CMI calculation but uses _______ and their associated
RWs. - Answer ambulatory payment classification
The CMI for Memorial Hospital is 1.245. Adding volume to which MS-DRG will
increase the CMI? - Answer MS-DRG 164, Major Chest Procedures with CC with a
RW of 2.5316
,Define case-mix index. - Answer Case-mix index is a single number that compares
the overall complexity of the healthcare organization's mix of patients with the
complexity of the average of all hospitals.
Service-mix index (SM) is used in which clinical setting? - Answer SMI is used for
the hospital outpatient setting where the primary classification system is APCs.
What is the OCE? - Answer The OCE is a software program designed to process
data for OPPS pricing and editing of claims.
Which RVU element is used in physician productivity analysis? - Answer The
WORK element is used in physician productivity analysis because it measures the
physicians' work, such as mental effort and judgment, technical skill, physical
effort, and psychological stress.
Why do insurance companies compare E/M levels of service distribution among
providers and physician practices? - Answer Insurance companies compare E/M
levels of distribution to identify areas of risk. Physicians use a strict set of
guidelines to establish levels of service, which allows for comparison among
providers and physician practices.
, Why is it important to adjust productivity goals based on the FTE status for
physician productivity analysis? - Answer Physician goals must be aligned with
their FTE status so that analysts can make apples-to-apples comparisons in their
analysis. Failure to adjust for FTE status will put physicians with less than 1.0 FTE
status at a disadvantage.
Why is the following statement false? "Adding volume to a clinical area will
always increase the CMI." - Answer This statement is false because if volume is
added to a MS-DRG with a relative weight lower than the facility's CMI, the CMI
will decrease, not increase.
Which piece of legislation penalizes federal contractors who knowingly file false
or fraudulent claims in order to defraud the US government? - Answer False
Claims Act
Nari is a compliance analyst at University Hospital. She is preparing an audit plan
for an upcoming inpatient audit. She has created a list of medical record numbers
for inpatient admissions from the last six months. She has selected the first record
on the list and then every fifth record thereafter. Which probability sampling
technique is Nari using? - Answer Systematic random sampling
questions and answers with
solutions.
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis.
Surgery for spinal fusion was cancelled after the patient was diagnosed with
mononucleosis. On today's visit the patient is started on prednisone for severe
sore throat and difficulty swallowing. The patient was accompanied by his parents
who have health insurance through the mother's employment at the State
Department of Treasury. Who is the first party in this healthcare reimbursement
scenario? - Answer Parents
An employee paying for 40 percent of the insurance premium through payroll
processing is an example of a transaction between ________ and ________. -
Answer Patient; employer
The national unadjusted payment amount is the product of the conversion factor
multiplied by the relative weight, unadjusted for __________. - Answer
Geographic factors
CMS has increased the weight for MS-DRG A by 14 percent, increased the weight
for MS-DRG B by 20 percent, and decreased the weight for MS-DRG D by 10
,percent. Given these new weights, which MS-DRG generated the most revenue
for Venice Bay Health Center? - Answer MS-DRG C
The MS-DRG that generated the most revenue for Venice Bay Health Center
is:Community Hospital collected the data displayed below concerning its four
highest volume MS-DRGs. - Answer MS-DRG C
Memorial Hospital's TOP 10 MS-DRGs
The case-mix index for the top 10 MS-DRGs above is: - Answer 1.2846
Which individual MS-DRG has the highest reimbursement? - Answer 247
SMI calculation is similar to CMI calculation but uses _______ and their associated
RWs. - Answer ambulatory payment classification
The CMI for Memorial Hospital is 1.245. Adding volume to which MS-DRG will
increase the CMI? - Answer MS-DRG 164, Major Chest Procedures with CC with a
RW of 2.5316
,Define case-mix index. - Answer Case-mix index is a single number that compares
the overall complexity of the healthcare organization's mix of patients with the
complexity of the average of all hospitals.
Service-mix index (SM) is used in which clinical setting? - Answer SMI is used for
the hospital outpatient setting where the primary classification system is APCs.
What is the OCE? - Answer The OCE is a software program designed to process
data for OPPS pricing and editing of claims.
Which RVU element is used in physician productivity analysis? - Answer The
WORK element is used in physician productivity analysis because it measures the
physicians' work, such as mental effort and judgment, technical skill, physical
effort, and psychological stress.
Why do insurance companies compare E/M levels of service distribution among
providers and physician practices? - Answer Insurance companies compare E/M
levels of distribution to identify areas of risk. Physicians use a strict set of
guidelines to establish levels of service, which allows for comparison among
providers and physician practices.
, Why is it important to adjust productivity goals based on the FTE status for
physician productivity analysis? - Answer Physician goals must be aligned with
their FTE status so that analysts can make apples-to-apples comparisons in their
analysis. Failure to adjust for FTE status will put physicians with less than 1.0 FTE
status at a disadvantage.
Why is the following statement false? "Adding volume to a clinical area will
always increase the CMI." - Answer This statement is false because if volume is
added to a MS-DRG with a relative weight lower than the facility's CMI, the CMI
will decrease, not increase.
Which piece of legislation penalizes federal contractors who knowingly file false
or fraudulent claims in order to defraud the US government? - Answer False
Claims Act
Nari is a compliance analyst at University Hospital. She is preparing an audit plan
for an upcoming inpatient audit. She has created a list of medical record numbers
for inpatient admissions from the last six months. She has selected the first record
on the list and then every fifth record thereafter. Which probability sampling
technique is Nari using? - Answer Systematic random sampling
