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Reimbursement according to a ______ means that hospitals reported actual charges for inpatient care to payersafter discharge of the patients from the hospital. - ANSWERSretrospective reasonable cost system Which is established in advance and based on reported health care charges from which a predetermined per diem rate is determined? - ANSWERSprospective cost based rate Which is associated with a particular category of patient and is established by the payer prior to the provision of healt...

LONG-TERM CARE HOSPITAL (LTCH) CERTIFICATION - ANSWERSLTCHs are certified under Medicare as short-term acute care hospitals and generally treat medically complex patients who require long-stay hospital-level care. For Medicare payment purposes, LTCHs are generally defined as having an average inpatient Length of Stay (LOS) greater than 25 days. MEDICARE SEVERITY LONG-TERM CARE DIAGNOSIS-RELATED GROUPS (MS-LTC-DRGs) - ANSWERSThe LTCH PPS uses MS-LTC-DRGs as a patient classification system. T...

When an insurance carrier makes a payment to the patient/insured (or the provider) for a covered expense, it is referred to as - ANSWERSreimbursement A payment system whereby the healthcare provider is paid a fee for each service or supply provided and fees are billed at rates established by the provider is referred to as - ANSWERSfee-for-service A type of reimbursement used by CMS that bases Medicare payments on a predetermined, fixed amount (e.g., DRGs for inpatient hospital services) is...

Inpatient Prospective Payment System (IPPS) - ANSWERSclassification system used to reimburse hospitals based on diagnosis-related groups (DRGs) with assigned payment weights based on average resource utilization for a particular diagnosis Diagnosis-Related Groups (DRGs) - ANSWERSclassification system that categorizes patients who are similar in terms of diagnoses and treatments, age, resources used, and length of stays based on the principal and secondary diagnoses including comorbidities and...

Which of the following concepts is a guiding principle for prospective payment? - ANSWERSPayment rates are established in advance of the healthcare delivery and are fixed for the fiscal period to which they apply. [There are 4 guiding principles of prospective payment: See pg 115 Payment rates are to be established in advance and fixed for the fiscal period to which they apply Payment rates are not automatically determined by the hospital's past or current actual cost. Prospective payme...

- Rising healthcare payments using the funds in the Medicare Trust at a rate faster than US workers were contributing dollars - Fraud and abuse in the system, wasting funding - Payment rules not uniformly applied across the nation. - ANSWERSReform in the federal method of reimbursing providers for healthcare services resulted from three trends: Inpatient Prospective Payment System (IPPS) - ANSWERSThe ______ system was the first provider type to go under a PPS by the government. October 1...

Acute-care prospective payment system - ANSWERSThe Medicare reimbursement methodology system referred to as the inpatient prospective payment system (IPPS). Hospital providers subject to the IPPS utilize the Medicare severity, diagnosis-related groups (MS-DRGs) classification system, which determines payment rates. Administrative services only (ASO) contract - ANSWERSAn agreement between an employer and an insurance organization to administer the employer's self-insured health plans. Am...

What does MS-DRG Stand for? - ANSWERSMedicare Severity Diagnosis Related Groups Acute Inpatient Settings - ANSWERSAddresses conditions that typically resolve quickly, such as injuries, urgent medical conditions like heart attack, Episodes of illness like pneumonia, surgical encounters, maternity and newborn admissions What does IPPS stand for? - ANSWERSInpatient Prospective Payment System What does IPPS do? - ANSWERSIt is the prospective payment system that Medicare uses to reimburse FA...

The hospital inpatient prospective payment system (IPPS) - ANSWERSIs a method of payment undertaken by CMS to control the cost of inpatient acute-care hospital services to Medicare recipients. Title VI of the Social Security Amendments of 1983 established the prospective payment system (PPS) to provide payment to hospitals for each Medicare case at a set reimbursement rate, rather than on a fee-for-service or per-day basis (CMS 2014a). The payment rates to hospitals, then, are established before...

Postacute Care (PAC) - ANSWERS= provides patients with healthcare services for their recuperation and rehabilitation after an illness or injury. = allows patients to safely continue their recovery in settings that are less intensive and more appropriate than acute-care inpatient hospitals. Medicare designates 4 settings as PAC: - ANSWERS1) Skilled Nursing Facilities (SNF) 2) Long-term Care Hospitals (LTCHs) 3) Inpatient Rehabilitation Facilities (IRFs) 4) Home Health Agencies (HHAs) ...