John's - Chapter 7

What is Title XVIII of Social Security Act
Health insurance program designed to complement the retirement, survivors, and disability insurance benefits for most Americans over the age of 65
What is Medicare
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What is Title XIX of Social Security Act
Program designed as a cost-sharing program between the federal and state government to allow people on public assistance programs for low-income groups, families with dependent children, the aged, and the disabled to have health insurance
What is Medicaid
Centers for Medicare and Medicaid Services (CMS)
How administers Medicare and Medicaid programs today
A type of reimbursement system that is based on preset payment levels rather than actual changes billed after the service has been provided; specifically, one of several Medicare reimbursement systems based on predetermined payment rates or periods and linked to the anticipated intensity of services delivered as well as the beneficiary’s condition.
What is PPS
Coverage for catastrophic illnesses and injuries.
What is major medical insurance
After the deductible has been paid, insured and insurer (third-party payer) shared covered losses according to specified ration, and the insured paid a coinsurance amount. Coinsurance refers to the amount the insured pays as a requirement of the insurance policy.
What is coinsurance
The healthcare expenses that the insured party is responsible for paying. After insured has paid an amount specified in the insurance plan (that is the deductible plus any copayments) the plan pays 100 percent of covered expenses.
What is Out-of-pocket expenses
policy holder or insured
Who pays the deductible
The amount of money that the patient is responsible for before the insurance kicks in
Out-of-pocket expenses
There term used to describe the money the insured patient pays on a claim is called Out-of-pocket expenses
Manage Medicare and Medicaid costs
Prospective payment systems were developed by CMS to
The government agency that administers the Medicaid and Medicare programs is
Group Health Insurance
To increase wartime labor during the Second World War, employers began offering
Catastrophic illnesses and injuries
Major medical insurance covers
Americans over age of 65
Which of the following was original group eligible for Medicare?
A method of reimbursement through which providers retrospectively receive payment based on either billed charges for services provided or on updated fee schedules; also called fee-for-service reimbursement
Fee-for service
A method of healthcare reimbursement in which an insurance carrier prepays a physician, hospital, or other healthcare provider a fixed amount for a given population without regard to the actual number of nature of healthcare services provided to the population
An umbrella term used to describe health plans that re funded directly by employers to provide coverage for their employees exclusively in which employers establish accounts to cover their employees medical expenses and retain control over the funds but bear the risk of paying claims greater than their estimates
Employer-based self-insurance
Amount of money that a policyholder or certificate holder must periodically pay an insurer in return for healthcare coverage
administrative services only contract. An agreement between an employer and an insurance organization to administer the employer’s self-insured health plan
What is ASO
Where the excess revenues are directed. For profit health plan, excess are distributed to shareholders. In nonprofit entities, excess revenues are not distributed to shareholders, but are retained for future internal investments. Quality of care, and performance of nonprofit is better than for profit.
What is the primary difference between nonprofit and for-profit entities.
Blue Cross and Blue Shield (BC/BS) Federal Employee Program (FEP) also called BC/BS Service Benefit Plan
What does federal employees have for health insurance
Part A, Part B, Part C and Part D
What are the four parts of Medicare
Hospital Insurance that helps cover inpatient hospital, skilled nursing, home health and hospice care
Medicare Part A
Medical Insurance that helps cover physician services, outpatient care, and home healthcare
Medicare Part B
Medical Advantage Plans (like an HMO or PPO) Includes par A and Part B and is operated by private insurance companies that are approved by and under contract with Medicare
Medicare Part C
Prescription Drug Coverage
Medicare Part C
Measured in “benefit periods”. Limited to 90 days during each benefit period. A benefit period begins on the day of admission and ends when the beneficiary has been out of the hospital 60 days in a row, including the day of discharge. No limit to the number of periods
Inpatient care for Medicare part A is
Is covered when a patient requires skilled nursing or rehabilitation services occurring with 30 days of a 3-day-long or longer acute hospitalization. SNF days is limited to 100 days per period.
Skilled Nursing Care
Care provided by a home health agency (HHA) may be furnished part-time in the residence of a homebound beneficiary when intermittent or part time skilled nursing and/or certain other therapy or rehabilitation care is needed.
Home Health Care
Certain medical supplies and durable medical equipment (DME) may be paid for under the Medicare home health benefit.
Can you get DME in home care or do you have to pay for them?
Medicare Part A has no limits on duration, no copayments, and no deductibles. For DME, beneficiaries must pay 20 percent
What is the limit on home health care with Medicare?
Medicare benefits for treatment of their terminal illnesses and agree to receive only hospice care. Medicare does pay for all covered services necessary for the condition. Pay no deductible for hospice coverage, but does pay coinsurance amounts for drugs and inpatient respite care
Hospice Care
For any Part A service, the beneficiary is responsible for paying fees to cover the first three pints or units of nonreplaced blood per calendar year. Beneficiary has the option of paying the fee or arranging for the blood to be replaced by family and friends
What about blood?
Voluntary supplemental medical insurance (SMI) to help pay for physicians services, medical services and medical-surgical supplies not covered by the hospitalization plan. Emergency department or outpatient clinic, home health care not covered under Part A; Laboratory tests, x-rays, and certain preventative care; Ambulatory surgery Centers; physical and occupational therapy; Radiation therapy, renal dialysis, transplants, DME approved for home use; Drugs and biologicals that cannot be self administered; Preventive services
What does Medicare part B pay for
Long-term nursing care; Custodial care; dentures and dental care; Eyeglasses; and hearing aids
What is not Covered by Part A or B
Provide expanded coverage of many healthcare services under Medicare Advantage. Offer extra coverage for services such as vision, hearing dental, and/or health and wellness programs.
What about Part C
Pays for prescription drugs
What about Part D
Private health insurance that pays within limits, most of the healthcare service charges not covered by Medicare Parit A and/or B
What is Medigap
Commercial insurance
Private health insurance is a type of
Hospitalization insurance
Medicare part A provides
Services in an emergency department; Ambulatory surgery center services; Services in an outpatient clinic
Medicare Part B covers
Individuals age 65 and over; Individuals who are disabled; Individuals who undergo chronic kidney dialysis for end-stage renal disease
Medicare coverage applies to
This is private health insurance that pays within limits, most of the healthcare service charges not covered by Medicare Part A and/or B
Medicaid is Title XIX. Healthcare coverage to low-income individuals and families.
What is Medicaid
Individual states must meet national guidelines established by federal statues, regulations, and policies to qualify for federal matching funds.
Medicaid Eligibility
Temporary Assistance for Needy Families
What is TANF
Program of All-Inclusive Care for Elderly. PACE provides an alternative to institutional care for individuals 55 years old or older who require a level of care usually provided at nursing facilities.
What is Pace
Functions within the Medicare program and allows beneficiaries to maintain their independence, dignity and quality of life.
What is main goal of PACE
Payer of last resort
Medicaid is always the payer of ?
State Children’s Health Insurance Program (SCHIP) (Title XXI) and allows states to expand existing services to cover children up to age 19.
What is SCHIP
Title XIX of the Social Security Act Amendment of 1965 is also known as
Individual States
Medicaid eligibility standards are established by
Inpatient hospital services; prenatal care; vaccines for children
To be eligible for federal matching funds, each state’s Medicaid program must offer medical assistance for
This program pays for medical assistance to individuals and families with low incomes and limited financial resources
Which program provides additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children
Civilian Health and Medical Program-Veterans Affairs (CHAMPVA) is a healthcare program for dependents and survivors of permanently and totally disabled veterans, survivors of veterans who died form service-related conditions, and survivors of military personnel who died in the line of duty
Indian health Services and provides healthcare services to American Indians and Alaska natives.
Workers compensation is a program that covers healthcare costs and lost income associated with work-related injuries and illnesses.
Workers Compensation
Federal employees Compensation Act (FECA)
What is workmen’s compensation called for federal government employees
administers by the Office of Workers Compensation Program (OWCP) within the US Department of Labor (DOL) Employment standards Administration (ESA)
what administers FECA
A healthcare program for actively duty members of the military and other qualified family members
Eligibility is based on eight priority groups
Eligibility for Veterans Health Administration is based on
A healthcare program for dependents and survivors of permanently and totally disabled veterans
Agency responsible for providing healthcare services to American Indians and Alaskan natives
Workers compensation is a program that covers healthcare costs and lost income associated with work-related injuries and illnesses.
Insurance that covers healthcare costs and lost income associated with work-related injuries
Federal employees Compensation Act (FECA)
FECA covers
A generic term for prepaid health plans that integrate the financial and delivery aspects of healthcare services. Control costs, and access to healthcare services at the same time that they strive to meet high-quality standards.
What is managed care
Health Maintenance Organization (HMO) Entity that combines the provision of healthcare insurance and delivery of healthcare services, characterized by (1) an organized healthcare delivery system to a geographic area (2) a set of basic and supplemental health maintenance and treatment services (3) voluntarily enrolled members and (4) predetermined fixed, periodic prepayments for members coverage
A paper or computer-based tool for collecting and storing information about the healthcare services provided to a patient in a single healthcare facility; also called a patient record, medical record, resident record, or client record, depending on the healthcare setting
A private, not-for-profit accreditation organization whose mission is to evaluate ad report on the quality of manage care organizations in the United States
Point-of-service plan. A type of managed care plan in which enrollees are encouraged to select healthcare providers from a network of providers under contract with the plan but are also allowed to select providers outside the network and pay a larger share of the costs
Exclusive provider organization (EPO) Hybrid managed care organization that provides benefits to subscribers only when healthcare services are performed by network providers; sponsored by self-insured (self-funded) employers or associations and exhibits characteristics of both health maintenance organizations and preferred provider organizations
Integrated deliver system (IDS) A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care.
Group Model HMO, Independent Practice association (IPA), the Network Model HMO and the staff model HMO
HMO can be organized in several different ways including
A type of health plan in which an HMO contracts with an independent multispecialty physician group to provide medical services to members of the plan
Group Model HMO
An open-panel health maintenance organization that provides contract healthcare services to subscribers through independent physicians who treat patients in their own offices; the HMO reimburses the IPA on a capitated bases; the IPA may reimburse the physician on a fee-for-service or a capitated basis
Independent Practice association (IPA) HMO
Program in which participating HMO contract for services with one or more multispecialty group practices
Network Model HMO
A type of health maintenance that employs physicians to provide healthcare services to subscribers
staff model HMO
Preferred provider Organization. A managed care arrangement based on a contractual agreement between healthcare providers (professional and/ or institutional) and employers, insurance carriers, or third-party administrators to provide healthcare services to a defined population of enrollees at established fees that may or may not be discount from usual and customary or reasonable charges
Group practices without walls (GPWWs); Integrated provider organizations (IPO); Management service organizations (MSO); Medical foundations; Physician-hospital organizations (PHO)
IDS deliver systems can be structured according to several different models. What are the models
A type of managed care contract that allows physicians to maintain their own offices and share administrative services
Group practices without walls (GPWW)
An organization that manages the delivery of healthcare services provided by hospitals, physicians (employees of the IPO), and other healthcare organizations (for example, nursing facilities)
Integrated provider organizations (IPO)
An organization, usually owned by a group of physicians or a hospital, that provides administrative and support services to one or more physician group practices or small hospitals
Management service organizations (MSO)
Multipurpose, nonprofit service organization for physicians and other healthcare providers at the local and county level; as managed care organizations, medical foundations have established preferred provider organizations, exclusive provider organizations and management service organizations, with emphases on freedom of choice and presentation of the physician-patient relationship
Medical foundations
An integrated delivery system formed by hospitals and physicians (usually through managed care contracts) that allows for cooperative activity but permits participants to retain some level of independence
Physician-hospital organizations (PHO)
Independent practice
This model of HMO is created when physicians join together in an organized group for the purposes of fulfilling a contract but retain individual practice
This model of HMO employs physicians and other healthcare professionals to provide healthcare services to members
In this model, healthcare services are contracted with two or more multispecialty group practices instead of just one
In this HMO contract, providers usually agree to devote a fixed percentage of their practice time to the HMO
Premiums are paid directly to this type of HMO, and services are usually provided within
Medical foundation
This nonprofit organization contracts with physicians to manage their practices and owns clinical/business resources that are made available to participating physicians:
Management service organization
This arrangement provides practice management services to individual physicians practices
Group practice without walls
In this arrangement physicians maintain their offices but administrative services
Integrated provider organization
This organization manages and coordinates the delivery of healthcare services performed by a number of healthcare professionals and facilities and its physicians are salaried employees:
Physician-hospital organization
This arrangement makes it possible for managed care market to view hospitals and physicians as a single entity for the purpose of contracting services.
Issue payments to healthcare providers on the basis of the charges assigned to each of the separate services that were performed for the patient
Fee-for-service reimbursement methodologies
Used to list the individual charges for every element entailed in providing a service (example, surgical supplies, surgical equipment, room and board)
Reimbursement systems, third-party payers and/or patients issue payments to healthcare providers after healthcare services have been provided. Aments are based on the specific services delivered.
Traditional fee-for service (FFS)
Usual, customary, and reasonable (UCR) charges. Method of evaluating providers fees in which the third-party payer pays for fees that are “usual” in that provider’s practice; “customary” in the community; and “reasonable” for the situation
What is UCR
A list of healthcare services and procedures (usually CPT/HCPCS codes) and the charges associated with them developed by a third-party payer to represent the approved payment levels for a given insurance plan, also called table of allowances
Fee Schedule
A review of patient’s health records before admission to determine the necessity of admission to an acute care facility and to determine or satisfy benefit coverage requirements. Also called precertification.
Prospective Utilization review
The part of the utilization review process that concentrates on a review of clinical information following patient discharge.
Retrospective utilization review
The process of coordinating the activities related to the release of a patient when inpatient hospital care is no longer needed
Discharge planning
Episode-of-Care (EOC) reimbursement. Lum-sum payment to providers to compensate them for all the healthcare services delivered to a patient. Bundled payment covers multiple services and also may involve multiple providers of care. EOC reimbursement methods include capitated payments, global payments, global surgery payments.
Bundled payment
What is another name for EOC
A method of healthcare reimbursement in which an insurance carrier prepays a physician, hospital, or other healthcare provider a fixed amount for a given population without regard to the actual number or nature of healthcare services provided to the population
Per patient per month or per member per month
Capitated premiums are calculated on
A form of reimbursement used for radiological and other procedures that combines the professional and technical components of the procedures and disperses payments as lump sums to be distributed between the physician and the healthcare facility
Global payment
Supplied by physicians (radiologists)
Professional component
radiological supplies, equipment and support services
Technical component
A payment made for surgical procedures that includes the provision of all healthcare services from the treatment decision through postoperative patient care
Global surgery payment
Diagnosis-related groups (DRG)
What is the PPS methodology called
Control Medicare spending. It reimburses hospitals a predetermined amount for each Medicare inpatient stay
DRG was implemented as a way to
Principal diagnosis
Payments are determined by the DRG to which each case is assigned according to the patient’s
Which is defined as the condition which, after study, is determined to have occasioned the admission of the patient to the hospital for care
Principal diagnosis
Omnibus Budge Reconciliation Act (OBRA)Which mandated the development of a prospective system for hospital-based outpatient services provided to Medicare beneficiaries. Subsequently, Congress mandated the development of PPS for other healthcare providers including SNF outpatient series and procedures, home healthcare and rehabilitation care
The type of payment system where the amount of payment is determined before the service is delivered
These payment arrangements are streamlined by the use of chargemaster:
This payment is based on the amount representing reasonable compensation for the service/procedure in a specific area of the country
80 – 20
The most typical cost share ratio between insurance plans and patients is
Prospective review
The utilization control most closely associated with managed fee-for-service
Lump-sum payment to providers to compensate them for all healthcare services delivered to a patient for a specific illness and/or over a specific period of time
Based on per-person premiums or membership fees
Prospective payment system implemented in 1983
Medicare paid hospitals for inpatient hospital services according to a predetermined rate for each discharge.
DRG PPS pays what
on the basis of diagnosis.
DRG system was a way of classifying patients
“Medically meaningful” that is, patients within a group were expected to evoke a set of clinical responses which statistically would result in an approximately equal use of hospital resources.
Patients within each DRG were said to be
Medicare severity diagnosis-related groups. US government’s 2007 revision of the DRG system. The MS-DRG system better accounts for severity of illness and resource consumption
25 major diagnostic categories, or MDC
To determine the appropriate MS-DRG, a claim for a healthcare encounter is first classified into one of
Is the condition established after study to have resulted in the inpatient admission
The principal diagnosis
On the basis of diagnosis and age
Medical MS-DRG generally are differentiated
The presence or absence of complications or comorbidities
Surgical and medical MS-DRG are further differentiated on the basis of
A secondary condition that arises during hospitalization and is thought to increase the length of stay by at least on day for approximately 75 percent of the patients
Complication is
A condition that existed at admission and is thought to increase the length of stay at least one day for approximately 75 percent of patients.
A Co-Morbid condition
By assigning ICD-9-CM codes to each patient’s principal diagnosis, comorbidities, complications, major complications, principal procedure and secondary procedure
Hospitals determine MS-DRG
A computer software program that signs appropriate MS-DRG according to the information provided for each episode of care
MS-DRG group
MS-DRG assigned
Reimbursement for each episode of care is based on
A description, a relative weight, a geometric mean length of stay (LOS), and arithmetic mean LOS
Each MS-DRG is associated with
Average resources required to care for cases in that particular MS-DRG relative to the national average of resources used to treat all Medicare patients.
Relative weight represents the
An outlier case results in exceptionally high costs when compared with other cases in the same DRG. To qualify for a cost outlier, a hospital’s charges for a case (adjusted to cost) must exceed the payment rate for the MS-DRG by $23,140. Additional payment is equal to 80 percent of the difference.
Disproportionate share hospital (DSH); Sole community hospitals (SCH); Medicare dependent hospitals (MDH); Indirect medical education; Graduate medical education (GME); New technologies
Hospital-specific adjustment resulting in add-on payments
Disproportionate share hospital: Treat a high percentage of low-income patients
Sole community hospitals (SCH) are hospitals located in rural region and are at least 35 miles form another like hospital
Medicare dependent hospitals (MDH) are small hospitals located in rural area and have a high percentage of Medicare discharges
Indirect medical education – Approved teaching hospital
Graduate medical education – A hospital is an approved teaching hospital that teaches residents
Use of new technology that is a substantial clinical improvement over available existing technologies and new technology is approved, additional payment is made
New technologies
Types or categories patients treated by the hospital based on the relative weights of the MS-DRG
Case-mix index
The case-mix index can be figured by multiplying the relative weight of each MS-DRG by the number of discharges within the MS-DRG. This provides the total weight for each MS-DRG. The sum of all total weights divided by the sum of total patient discharges equal the case-mix index
How do you computer case mix
All patient DRG (AP-DRG) A case-mix system developed by 3M and used in a number of state reimbursement system to classify non-Medicare discharges for reimbursement purposes
Deficit Reduction Act of 2005 mandated a quality adjustment in the MS-DRG payment for certain hospital acquired conditions.
Hospital Acquired Condition (HAC) Select, reasonalbly preventable conditin for which hospitls do not receive additonal payemtn when one of the conditions was nto present on admission
Present on admission (POA) is defined as a condition present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter , including the emergency department, observation or outpatient surgery, are considered present on admission
Principal and secondary diagnoses and the external cause of injury codes
POA indicators are assigned to
Yes (Y); No (No); U (Unknown); W (Clinically undetermined; Unreported/Not used
What are the reporting option that are available for POA
Yes, diagnosis was present at time of inpatient admission
POA reporting option Yes
No, diagnosis was not present at time of inpatient admission
POA reporting option No
The provider is unable to clinically determine whether the condition was present at the time of admission
POA reporting Unknown documentation
Clinically undetermined. The provider is unable to clinically determine whether the condition was present at time of admission
POA reporting W
Exempt form POA reporting
POA reporting option Unreported/not used
Hospital-acquired condition – Select, reasonably preventable conditions for which the hospital do not receive additional payment when one of the conditions was not present on admission (Foreign object retained after surgery; air embolism; blood incompatibility)
Resource-based relative value scale. A Medicare reimbursement system implemented in 1992 to compensate physicians according to a fee schedule predicted on weights assigned on the basis of the resources required to provide the services
Medicare fee schedule (MFS) is the listing of allowed changes that are reimbursable to physician under Medicare
Relative value Unit is used to calculate fee schedule amounts. The formula is Physician Work (RVU); Practice expense (RVU); and Malpractice costs (RVU)
Geographic practice cost indices (GPCI and payment is localities are adjusted. The GPCI are Physician work (GPCI); Practice expense (GPCI) and Malpractice costs
What are the GPCI
National conversion factor (CF) converts the RVU into payment
What is the CF
[(RVUw x GPCIw) + (RVUpe x GPCIpe) + (RVUm x GPCIm)] x CF = Payment
What is the RBRVS fee schedule formula
Skilled nursing facility Prospective Payment System. SNF services furnished to Medicare Part A beneficiaries.
Resident Assessment instrument (RAI) and includes the Minimum data Set (MDS)
Instrument to standardize the collection of SNF patient data
Is the minimum core of defined and categorized patient assessment question that services as the basis for documentation and reimbursement in SNF
what is the MDS
Resource Utilization Groups (RUG) is a resident classification system) based on MDS resident assessment in SNF
Resident Assessment Validation and entry (RAVEN) is data-entry software for long-term care facilities that offers users the ability to collect MDS assessments in a database and transmit them in CMS-standard format to their state database
A health plan that process Part b claims for services by physicians and medical suppliers (Blue shield plan in a state)
Medicare carrier
Healthcare Common Procedure Coding System (HCPCS) An alphanumeric classification system that identifies healthcare procedures, equipment and supplies for claim submission purposes.
Outpatient prospective payment system (OPPS). Under OPPS the federal government pays for hospital outpatient services on a rate-per-service basis that varies according the ambulatory payment classification (APC) group to which the service is assigned
Ambulatory payment classification group (APC) Basic unit of the ambulatory payment classification (APC) system. Within a group, he diagnoses and procedures are similar in terms of resources used, complexity of illness, and conditions represented. A single payment is made for the outpatient services provided and is based on HCPC/CPT codes.
Ambulatory Payment Classification Groups (APG). The calculation of payment for services under the OPPS is based on the categorization of outpatient services into APC groups according to CPT/HCPC code. ICD-9 is not utilized in selection of APC. APC is assigned a fixed payment rate for the facility fee or technical component of the outpatient visit. Payment rates are also adjusted according to the hospital’s wage index
payment status indicators (PSI) the OPPS PSI are assigned to each HCPCS code and APC play an important role in determining payment for services under the OPPS. An CPT/HCPCS codes to indicate whether a service or procedure is to be reimbursed under the Medicare outpatient prospective payment system
Means that payment for the service sis packaged into payment for other services and therefore, no separate APC payment
Applies to multiple surgical procedures furnished during the same operation session.
Services paid under some other method
Status Indicator A
Codes that are not recognized by OPPS when submitted on an outpatient hospital
Status Indicator B
Inpatient procedure
Status Indicator C
Discontinued cod
Status Indicator D
Items, codes, and services not covered by Medicare
Status Indicator E
Corneal tissue acquisition, certain CRNA services and Hepatitis b vaccines
Status Indicator F
Pass-through drugs and biologicals
Status Indicator G
Pass-through device categories
Status Indicator H
Non-Pass-thorough drugs; non-implantable biologicals, and therapeutic
Status Indicator K
Influenza vaccine
Status Indicator L
Items and services not billable to the fiscal intermediary MAC
Status Indicator M
Items and services packaged into APC rates
Status Indicator N
Partial hospitalization
Status Indicator P
Packaged services subject to separate payment under OPPS payment criteria
Status Indicator Q
Blood and blood products
Status Indicator R
Significant procedure, not discounted when multiple
Status Indicator S
Significant procedure, multiple reduction applies
Status Indicator T
brachytherapy services
Status Indicator U
Clinic or emergency department visit
Status Indicator V
non-implantable durable medical equipment
Status Indicator Y
Ancillary Services
Status Indicator Z
Ambulatory Surgery Center (ASC) Prospective Payment System (PPS) is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. ASC is either independent or operated by a hospital. ASC must accept assignment as payment in full
It has to be a separately identifiable entity physically administratively, and financially
To be considered an ASC of a hospital –
0 percent payment for procedures terminated for reasons before the ASC has expanded substantial resources; 50 percent payment for procedures that are terminated due to medical complications prior to anesthesia; 100 percent payment for procedures that have started but are terminated after anesthesia is induced
OPPS guidelines for payment of terminated procedures
Home Health Prospective Payment System (HH PPS) for reimbursement of services provided to beneficiaries to home health agencies (HHA)
OASIS – Outcome and Assessment Information Set and consists of data elements that represent core items for comprehensive assessment of an adult home care patient and form the basis for measuring patient outcomes for the purpose of outcome-based quality improvement (OBQI).
What is the Home health data set called
HAVEN (Home Assessment Validation and Entry) is the data-entry software to conduct all patient assessments
What is the software used by Home Health agencies called
Home health resource group (HHRG) represent the classification system established for the prospective reimbursement of covered home care services during a 60 day episode of care.
Skilled nursing visits, home health aid visits, therapy services, medical social services and nonroutine medical supplies
What are the covered services for Home health services
Durable Medical equipment (DME) is excluded from the episode of care payment and is reimbursed under the DME fee schedule
Low-utilization payment adjustment is made instead of a full HHRG reimbursement if fewer than four home care visits are made in a 60-day episode
A Prospective system for ambulance services, including volunteer, municipal, private independent, and institutional providers (hospitals, critical access hospitals, SNF and HHA
Medicare Ambulance Fee Schedule
Basic life support; Advanced life support, Level 1 and 2; Fixed wing are ambulance; specialty care transport; paramedic intercept; and rotary wing air ambulance
What are the categories of ambulance service
Inpatient Rehabilitation facilities (IRF) Prospective Payment System. A healthcare facility that off specializes in providing services to patients who have suffered a disabling illness or injury in an effort to help them achieve or maintain their optimal level of functioning, self-care and independence
Requirements state that during the most recent, consecutive and appropriate 12-month time period, the hospital will treat an inpatient population of whom at least 60 percent require intensive rehabilitative services for treatment of one or more of 12 medical conditions
What are the equipments that must be meet to use a IRF.
Patient assessment instrument (PAI) upon each patient admission and discharge from the facility.
What must IRF required to complete an a patient
RAVEN Rehabilitating Validation and Entry
What is the software that is used to collect the IRF-PAI
Case-mix group,
IRF PPS uses information from the IRF-PAI to classify patients into distinct groups on the basis of clinical characteristics and expected resource needs. Data used to construct these groups is called
Functional status (both motor and cognitive), age, comorbidities and other factors deemed appropriate to improve thee explanatory power of the groups
CMG, include rehabilitation impairment categories (RRIC) that do what
CMG relative weight
An appropriate weight is called the
Each case-mix group and measures the relative difference in facility resource intensity among the various groups. Separate payment is calculated for each group, including the application of case and facility level adjustments.
CMG relative weight is assigned to
Long term Care Hospital is defined as having an average inpatient LOS greater than 25 days.
patients are classified into distinct diagnosis groups based on clinical characteristics and expected resource use. Based on current inpatient MS-DRG
Short-stay outlier, interrupted stays, and high-cost outliers. Facility wide adjustments include area wage index and cost of living adjustments.
Adjustments for PPS LTC are done for
Prospective Payment System (PPS) Inpatient Psychiatric Facility is based on the national average of operating, ancillary, and capital cost for each patient day of care in the IPF
Patient-level or case-level adjustment are provided for age, specified MS-DRG, and certain comorbidity categories. Made for eight age categories beginning with age 45, at which point, statistically, cost are increased as the patient ages
Adjustments for PPS IPF
Patient had 3 visits in 60 day period
Which of the following patients qualify for a LUPA
Fee-for-service reimbursement methodology
Prior to implementation of the DRG Prospective Payment system, Media Part A payments to hospitals were based on a
The MS-DRG prospective payment system rate is based on what type of diagnosis
The computer software program that assigns appropriate MS-DRG according to information provided for each episode of care is called a
Children; Critical Access Hospital; Psychiatric and rehabilitation hospitals Long-term care hospitals; Cancer hospitals
Which of the following hospitals are excluded form Medicare acute care prospective payment systems
Major diagnostic categories
MS-Diagnostic-related groups are organized into
What reimbursement system utilizes the Medicare fee schedule
What legislation mandated the implementation of a skilled nursing facility prospective payment system
Which of the following is the tool used to collect resident assessment data so that the SNF resident can be assigned the appropriate resource utilization group
hat reimbursement system is associated with the Medicare outpatient prospective payment system
Critical Access Hospital; Psychiatric and rehabilitation hospitals Long-term care hospitals; Cancer hospitals
Which of the following types of organization is not reimbursed under the outpatient prospective payment system?
Discounting of procedures
Which of the following concepts is applied when multiple surgical procedures are furnished during the same operative session
What data set is used for patient assessments by the home health prospective payment system
Per diem rate
The inpatient psychiatric facility prospective reimbursement system is based on
What tool is used to calculate the CMG
Coordination of benefits (COB) or coordination of benefits transaction
In many instances patients have more than one insurance policy and the determination of which policy is primary and which is secondary is necessary so there is no duplication. This process is called
Healthcare facilities submit claims via electronic format(screen 8371) which replaces the UB-04 (CMS-1450)
What is UB-04
Physician submit claims via the electronic format (screen 837P), which takes the place of the CMS-1500 billing form.
What is the CMS-1500
Statement sent by third party payer to the patient to explain series provided, amounts billed, and payments made by health plan
Medicare Summary Notice (MSN) to a beneficiary to show how much the provider billed, how much Medicare reimbursed the provider, and what the patient must ay the provider by way of deductible and copayments
National Correct Coding Initiative (NCCI) was developed to improve the appropriate payment of Medicare part B claims and is based on Coding conventions defied in the CPT codebooks; National and local policies and coding edits; Analysis of standard medical and surgical practice; Review of current coding practice
Outpatient code editor (OCE) – A software program linked to the Correct Coding Initiative that applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent the services provided.
There are instances when it is necessary to query the physician for clarification of data that may influence proper code assignment. Includes conflicting or incomplete information in record.
Physician Query Process
Electronic data interchange (EDI) is the electronic transfer of information such as health claims transmitted electronically, in a standard format between trading partners.
Medicare Summary Notice (MSN)
The hospital needs to know how much Medicare paid on a claim so they can bill the secondary insurance. What should they refer to?
Monies made to the healthcare provider cannot exceed charges
A patient has two health insurance policies: Medicaid and a Medicare supplement. Which statement is true?
Whether or not data that were submitted electronically were successfully submitted
Which of the following situations would be identified by the NCCI edits?
Improve documentation
The purpose of physician query is to
Medicare carrier and fiscal intermediaries serve as the financial agent between providers ant eh federal government to locally administer Medicare Part A and B
The 837P is submitted to Medicare carriers to process hospital outpatient claims
The 837I is also referred to as the 837P?
The 837I is submitted to Medicare fiscal intermediaries and the 837P is submitted to Medicare carriers
The abbreviations used to describe electronic transfer of information such as claims submission is EDI
The OCE applies a set of logical rules
Means provider or supplier accepts , as payment in full, the allowed charge (from the fee schedule). Provider or supplier is prohibited from balance billing, which means the patient cannot be held responsible for charges in excess of Medicare fee schedule
Accept Assignment
Notice of exclusion from Medicare benefits
Participating providers may bill patients for services that are not covered by Medicare. Physicians must notify a patient that the service will be paid by giving the patient a
Advance Beneficiary Notice (ABN) A statement signed by the patient when he or she is notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for the service, wherein the patient indicates that he will be responsible for any charges
Do not sign a participation agreement with Medicare but may or may not accept assignment. If a physician elects to accept assignment he or she is paid 95% less (5%) less than participating physicians for MFS ( If MFS is $200 the Par provider receives 80 percent of 200) but the no-par provider receives only 152 (95 % of 160)
Nonparticipating providers (nonPAR)
Medicare’s limiting charge rule, which state that a physician may not charge a patient more than 115Percent of the nonparticipating schedule.
Non participating provider who choose not to accept assignment are subject to
Is to allow the provider to accurately charge routine services and supplies to the patient. Services, supplies and procedures included on the chargemaster generate reimbursement for almost 75 percent of UB-92 claims submitted for outpatient services alone.
Primary purpose of chargemaster
Description of service; CPT/HCPCS code; Revenue code (also called UP-04 code); Charge amount; Charge or service code; General ledger key; Activity/status date
Common elements of chargemaster
Representative from health information management, clinical services finance, the business office/patient financial services, compliance, and Information systems.
maintenance of the chargemaster is best accomplished by
Charge description Master is updated when new CPT codes became available, when departments request a new item, and when the medical fee schedules/ PPS rates are updated
When is CDM
Involves many different processes and people all working to make sure that the healthcare facility is properly reimbursed for services.
Revenue Cycle Management
Proclaims submission activities; Claims processing activities; accounts receivable; claims reconciliation and collections
The major components of the revenue cycle are
This portion of the revenue cycle is responsible for collecting the patient’s and responsible parties information completely and accurately for determining the appropriate financial class, education the patient as to his or her ultimate financial responsibility for services rendered, collecting waivers when appropriate, verifying data prior to procedures/services being performed and submitted for payment.
Proclaims Submission activities
Include the capture of all billable services, claim generation, and claim corrections (Charge capture is a vital component of the revenue cycle). Coding by HIM (health information management professionals); Auditing and review identifies data that has failed edits and flags the claim for review; Submission of the claim and RA(Remittance advice)
Claims Processing Activity
Manages the amounts owed to a facility by customers who received services but whose payment will be made at a later data be the patient or their third-party
Accounts Receivable
The day the bill drops. Day enough information is received to submit the bill
When does AR begin
Last component of the revenue cycle is reconciliation and collection. Uses EOB, MSN and RA to reconcile accounts. EOB and MSN identify the amount owed by the patient to the facility. Facilities can review the RA and determine whether the claim error can be corrected and resubmitted for addition payment. If a correction is not warranted, reconciliation can be made via write-off or adjustment to the patient’s account. Once the account has been settled, the revenue cycle is completed.
Claims Reconciliation and Collection
Purpose of Revenue Cycle management (RCM)is to improve the efficiency and effectiveness of the revenue cycle process. To identify issues to improve accounts receivable. To communicate issues with appropriate areas. To develop educational materials such as revenue cycle manual. To create a map or blue print on how to bring up new services. To review denials and actively discuss the appeal process and successes. To discuss key performance indicators and measures
Revenue Cycle Management Team
An effective method for managing the revenue cycle is through a revenue cycle management committee or team composed of individuals from all the departments involved in the revenue cycle.
Revenue cycle management committee
A program unveiled in 1998 by the Office of the Inspector General (OIG) that encourages providers to voluntarily report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs
Voluntary Disclosure Program
Recover Audit Contractor Program
Providences with another tool for detecting improper payments made in the past and has given CMS a valuable mechanism for preventing future inappropriate payments
RAC program
Automated reviews and complex review
Types or RAC audits
Fee schedules are updated by third-party payers
Provider accepts as payment in full whatever the payer reimburses
To accept assignment means that the
Developed by third-party payers and includes a list of healthcare services and procedures and charges of each
A fee schedule
Overpayments; Underpayments; Claim rejection
An inaccurately generated chargemaster affects reimbursement, resulting in
accusation of fraud and abuse
The goal of coding compliance programs is to
The practice of assigning a diagnosis or procedure code specifically for the purpose of obtaining a level of payment is called upcoding
The essential elements of a Corporate Compliance Program are defined by

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