Ch. 4-Healthcare Reimbursement Methodologies

Question 1

Accountable care organization (ACO)

Answer 1

Population-based model for healthcare delivery and payment

Question 2

Allowable charge

Answer 2

Amount the third-party payer or insurance company will pay for a service

Question 3

Attribution

Answer 3

Assignment of a beneficiary to a particular organization (may be an ACO)

Question 4

Billed charges

Answer 4

Price assigned to a unit of medical or health services, such as a physician’s visit or day in hospital

Question 5

Bundled payment

Answer 5

Reimbursement methodology where a predetermined payment amount is provided for all services required for a single predefined episode-of-care

Question 6

Capitation

Answer 6

Method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount for a period

Question 7

Case-rate methodology

Answer 7

Type of prospective payment method in which the third-party payer reimburses the provider a fixed, preestablished payment for each case

Question 8

CMS hierarchical condition categories (CMS-HCC) model

Answer 8

Risk adjustment model that uses patient demographic characteristics and medical conditions to predict the patient’s healthcare costs
Used in Medicare Advantage and Medicare value-based purchasing programs

Question 9

Fee schedule

Answer 9

Third-party payer’s predetermined list of maximum allowable fees for each healthcare service

Question 10

Global payment method

Answer 10

Method of payment in which the third-party payer makes one consolidated payment to cover the services of multiple providers who are treating a single episode-of-care

Question 11

One-sided risk

Answer 11

Type of risk used in ACO payment methodology where the ACO can share in any savings generated by the organization, but are not subject to any sharing of the cost if there is not savings or if the cost of care is higher while patients are attributed to the ACO

Question 12

Payment

Answer 12

The amount paid to a healthcare provider for services provided to a patient

Question 13

Per diem payment

Answer 13

Type of retrospective payment method in which the third-party payer reimburses the provider a fixed rate for each day a covered member is hospitalized

Question 14

Per member per month (PMPM)

Answer 14

The amount of money paid each month for individuals enrolled in the health insurance plan under a capitation reimbursement methodology

Question 15

Percent of billed charges

Answer 15

Type of retrospective reimbursement methodology where the payer negotiates to reimburse the facility or provider a percentage of the charge amount for a service, supply, procedure, or conferment period

Question 16

Prospective reimbursement

Answer 16

Type of reimbursement in which the third-party payer establishes the payment rates for healthcare services in advance for a specific time period

Question 17

Retrospective reimbursement

Answer 17

Type of reimbursement in which the payer bases payment on the actual resources expended to deliver the service(s)

Question 18

Risk adjustment

Answer 18

Statistical process that considers the underlying health status and health spending of patients when examining their healthcare outcomes or healthcare costs

Question 19

Two-sided risk

Answer 19

Type of risk used in ACO payment methodology where the ACO must share in the loss if the cost of care for their attributed beneficiaries is greater than the benchmark as well as any savings if the cost of care is lower than the benchmark