Reimbursement Methodologies Practice
Questions and Correct Answers
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
the healthcare provider to pay a flat fee per individual enrolled in the healthcare plan.
The actual services provided to the patient - few or numerous - dont affect the
reimbursement to the provider
PMPM ✅Per Member Per Month
Global Payment/ Prospective Payment Systems ✅fixed amount of money or lum-sum
payment designated to cover a related group of services
Prospective (payment system): The act of looking forward ✅when the costs of
healthcare services are projected and allowable reimbursement amounts set for future
healthcare services
Example of global prospective payment system ✅Medicare used for home health
services.. HHPPS. Medicare pays home health agencies (HHA) predetermined base
pay - which is adjusted for condition and care needs - geographic differences in wages
for HHA.
Medicare Pays HHA for ✅speech therapy, physical therapy, occupational therapy,
nursing visits, home health aide visits, and other in lump sum to HHA
Home Health Prospective Payment System (HHPPS) ✅prospective payment system -
reimbursement rates are set in advance for home healthcare. Paid for 60-day blocks of
time.
HHPPS multiplier ✅HHRG - home health resource group - set fixed rate for home
service based on historical data. Adjustments made for severely acute patients or for
receiving care in more or less expensive geographic areas.
Adjustment to basic rate ✅called case-mix adjustment and is done with the use of an
OASIS form (outcome and assessment information set)
HHPPS global payment system ✅1. Govt sets reimb. rate based on historical data for
home healthcare costs
2. patient receives care
, 3. documentation coded
4. HHA completes assessment (OASIS) to adjust variables
5. claim sent to Medicare/Medicaid
6. claim reimbursed lump sum
7. $$ to HHA and dispersed to providers
Prospective Payment Systems ✅third-party payer is interested in looking at averages
over time and paying the average cost for each patient instead of the actual cost. Based
on time units or based on services for specific conditions or disease
Example of time unit based ✅Indian Health Services IHS - sets per-diem (daily) rate
Prospective payment system based on disease or condition ✅1. paymt is not made on
individual services but on predetermined calculated rates
2. predetermined calculated rates are based on historical data
3. pps are based on averages of actual data and projections not on individual services
provided
Outpatient Prospective Payment System ✅reimbursed buy Medicare and Medicaid
thru pps known as the outpatient prospective pymt system
Ambulatory Payment Classifications (APC) ✅clinical services that require similar
resources are grouped together. A coding a reimbursement hierarchy for outpatient
services that organizes CPT and HCPCS codes into several hundred groups.
APC assignment does NOT ✅change based on the diagnosis or condition of the
patient.
Only THIS drives reimbursements ✅CPT/HCPCS codes
APC - 10 types identified by payment status indicator ✅Payment Status Indicator
Value
Clinic or emergency department visit V
Significant procedures, multiple reduction applies T
Significant procedure, not discounted when multiple S
Ancillary service X
Non-pass-through drugs and nonimplantable biological agents including therapeutic
radiopharmaceuticals K
Pass-through drugs or biological agents G
Pass-through device categories H
Partial hospitalization P
Blood and blood products R
Brachytherapy sources U
Questions and Correct Answers
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
the healthcare provider to pay a flat fee per individual enrolled in the healthcare plan.
The actual services provided to the patient - few or numerous - dont affect the
reimbursement to the provider
PMPM ✅Per Member Per Month
Global Payment/ Prospective Payment Systems ✅fixed amount of money or lum-sum
payment designated to cover a related group of services
Prospective (payment system): The act of looking forward ✅when the costs of
healthcare services are projected and allowable reimbursement amounts set for future
healthcare services
Example of global prospective payment system ✅Medicare used for home health
services.. HHPPS. Medicare pays home health agencies (HHA) predetermined base
pay - which is adjusted for condition and care needs - geographic differences in wages
for HHA.
Medicare Pays HHA for ✅speech therapy, physical therapy, occupational therapy,
nursing visits, home health aide visits, and other in lump sum to HHA
Home Health Prospective Payment System (HHPPS) ✅prospective payment system -
reimbursement rates are set in advance for home healthcare. Paid for 60-day blocks of
time.
HHPPS multiplier ✅HHRG - home health resource group - set fixed rate for home
service based on historical data. Adjustments made for severely acute patients or for
receiving care in more or less expensive geographic areas.
Adjustment to basic rate ✅called case-mix adjustment and is done with the use of an
OASIS form (outcome and assessment information set)
HHPPS global payment system ✅1. Govt sets reimb. rate based on historical data for
home healthcare costs
2. patient receives care
, 3. documentation coded
4. HHA completes assessment (OASIS) to adjust variables
5. claim sent to Medicare/Medicaid
6. claim reimbursed lump sum
7. $$ to HHA and dispersed to providers
Prospective Payment Systems ✅third-party payer is interested in looking at averages
over time and paying the average cost for each patient instead of the actual cost. Based
on time units or based on services for specific conditions or disease
Example of time unit based ✅Indian Health Services IHS - sets per-diem (daily) rate
Prospective payment system based on disease or condition ✅1. paymt is not made on
individual services but on predetermined calculated rates
2. predetermined calculated rates are based on historical data
3. pps are based on averages of actual data and projections not on individual services
provided
Outpatient Prospective Payment System ✅reimbursed buy Medicare and Medicaid
thru pps known as the outpatient prospective pymt system
Ambulatory Payment Classifications (APC) ✅clinical services that require similar
resources are grouped together. A coding a reimbursement hierarchy for outpatient
services that organizes CPT and HCPCS codes into several hundred groups.
APC assignment does NOT ✅change based on the diagnosis or condition of the
patient.
Only THIS drives reimbursements ✅CPT/HCPCS codes
APC - 10 types identified by payment status indicator ✅Payment Status Indicator
Value
Clinic or emergency department visit V
Significant procedures, multiple reduction applies T
Significant procedure, not discounted when multiple S
Ancillary service X
Non-pass-through drugs and nonimplantable biological agents including therapeutic
radiopharmaceuticals K
Pass-through drugs or biological agents G
Pass-through device categories H
Partial hospitalization P
Blood and blood products R
Brachytherapy sources U
