Healthcare Financing and Reimbursement

Question 1

What has made it difficult for the average american to pay for their healthcare without insurance?

Answer 1

Rising costs

Question 2

Why was private healthcare originally created?

Answer 2

To cover catastrophic injuries or impatient (hospital) admission.

Question 3

How do insurance groups displace the risk of insuring an individual?

Answer 3

Through group cost sharing

Question 4

What does HMO stand for?

Answer 4

Health Maintenance Organization

Question 5

What are elements of an HMO?

Answer 5

Case management and protective payment systems, primary care provider is the the gatekeeper of all services, must go to group providers only, co-pays to avoid moral hazard.

Question 6

Define PPO.

Answer 6

Preferred Provider Organization

Question 7

What are elements of a PPO?

Answer 7

Patients will be seen non preferred providers, but the cost share increases significantly for the patient.

Question 8

What was social security created as?

Answer 8

“age entitlement”

Question 9

What year did the social security act pass?

Answer 9

1935

Question 10

What is the primary function of the social security act?

Answer 10

Provide monetary benefits to American citizens and legal residents 65 +, to reduce dependency on their families.

Question 11

How is social security designed?

Answer 11

As a pay as you go system.

Question 12

How is Social Security funded?

Answer 12

By payroll taxes from employees and employers

Question 13

True or False, As long as the amount of contributions from workers exceeds those paid to beneficiaries the program can continue?

Answer 13

True

Question 14

Who is eligible for Social Security?

Answer 14

American Citizens, legal residents, 65 yro +, totally permanently disabled who have paid into the system for at least 10 years or married to someone that is eligible

Question 15

How are the amount of benefits determined for social security?

Answer 15

By calculating the average salary over 35 years

Question 16

What does SSI stand for?

Answer 16

Supplemental Security Income

Question 17

When was the SSI established?

Answer 17

1965 by title XVI of the social security act

Question 18

What does SSI do?

Answer 18

It provides a minimum level of economic support for older adults.

Question 19

What are the requirements to qualify for SSI?

Answer 19

Vert low income

Question 20

How are SSI payments calculated?

Answer 20

Payments are calculated on the total monthly income with supplementation to the max allowed by state of residence.

Question 21

When was Medicare enacted?

Answer 21

In 1965 XVII social security act

Question 22

What is the purpose of Medicare?

Answer 22

To provide insurance coverage for elderly and disabled regardless of financial situations.

Question 23

What is Medicare administered by?

Answer 23

The Centers of Medicare and Medicaid Services (CMS)

Question 24

Who is eligible for Medicare?

Answer 24

Legally worked for 10 + years, be at least 65 yro, if younger than 65 must have severe disabilities. Coverage may be bought.

Question 25

What does medicare cover?

Answer 25

Selected services, but they must be medically necessary

Question 26

What is Medicare part A?

Answer 26

The hospital insurance plan

Question 27

What does part A cover?

Answer 27

acute care, acute and short term rehab, some costs associated with hospital stays, home health under some circumstances.

Question 28

What is the deductible for acute care days 1 - 60?

Answer 28

$1260

Question 29

What is the copay for days 61 - 90?

Answer 29

$315 a day

Question 30

How many "lifetime days" does an individual get?

Answer 30

60

Question 31

What is the copay per lifetime day?

Answer 31

$630

Question 32

True or False, Copays are repeated every time the person is readmitted to acute care facility with a few exceptions?

Answer 32

True

Question 33

What % of the costs of the first 20 days in a skilled nursing facility for the purpose of rehab does medicare part A cover?

Answer 33

100%

Question 34

What will medicare part A not cover for a skilled nursing facility?

Answer 34

When only assistance with personal care or medication supervision is needed.

Question 35

What is Medicare part B?

Answer 35

It is purchased plan to cover some of the costs of services

Question 36

What is the approximate cost of Medicare part B?

Answer 36

$104.90 per month.

Question 37

What is the yearly deductible for Medicare part B?

Answer 37

$147

Question 38

What doe Medicare part B cover?

Answer 38

Outpatient services like lab work, PT, OT, yearly physical and welcome to medicare physical within 12 months of the 65th birthday.

Question 39

What is another name for Medicare part C?

Answer 39

Advantage

Question 40

What does Medicare part C cover?

Answer 40

Covers services through a PPO or HMO. Provides extra benefits beyond those usually covered by part B.

Question 41

What does Medicare part D cover?

Answer 41

Medications

Question 42

All medicare part D plans have what?

Answer 42

An annual deductible and a certain amount of coverage until a cap occurs.

Question 43

What is Medical?

Answer 43

Heather insurance for the low income, anyone who receives SSI and includes infants - elderly.

Question 44

What does Medical do for older adults?

Answer 44

Helps them offset the high Medicare copays and deductibles.

Question 45

What does medical cover.

Answer 45

More than Medicare, it includes custodial care, preventive care with no copays or deductibles.

Question 46

Under Medi-Medi who covers hospital deductibles?

Answer 46

Medical

Question 47

For Medi-Medi Medical pays for what?

Answer 47

Part B, Drug Plan, and LTC

Question 48

What is the best plan for low income older adults?

Answer 48

Medi-Medi

Question 49

Who is the largest healthcare payer in the United States?

Answer 49

CMS

Question 50

True or false people can chose to purchase long term care insurance?

Answer 50

True

Question 51

When is the best time to purchase LTC insurance?

Answer 51

Usually in 60's

Question 52

Define Revenue Cycle.

Answer 52

All administrative and clinical functions that contribute to the capture, management, and collection of patient services revenue.

Question 53

What are the 5 basic components of the Revenue Cycle?

Answer 53

Intake, Utilization review, health information management and coding, billing and flames. collections.

Question 54

Define intake in the revenue cycle.

Answer 54

patient registration, insurance identification, insurance verification

Question 55

Define utilization review in the revenue cycle.

Answer 55

Pre-certification, pre-authorization, continued-stay reviews, appeals

Question 56

Define health information management and coding in the revenue cycle.

Answer 56

documentation and coding

Question 57

define billing and coding in the revenue cycle.

Answer 57

bill generation, claims submission, claims correspondence and inquires

Question 58

Define collections in the revenue cycle.

Answer 58

Accounts receivable collections, payment posting/processing, denial management, collections correspondence and inquires

Question 59

What is it called when a claim is submitted to payer for reimbursement for services rendered?

Answer 59

Billing

Question 60

Why can claims be denied?

Answer 60

Incomplete information (missing data pieces)

Question 61

Why can claims be rejected?

Answer 61

Due to coding errors, medical necessity issues, coverage or eligibility issues.

Question 62

What is receiving and posting a payment called?

Answer 62

Collections

Question 63

Define EBO

Answer 63

Explanation of benefits,the statement that covers the payment and shows amounts paid and explains things that are not paid or partially paid.

Question 64

Define denial management.

Answer 64

Examining codes and remark codes to determine the reasons for claim denial.

Question 65

Define DRG.

Answer 65

Diagnostic Related Groups

Question 66

Define APC

Answer 66

Ambulatory Payment Organizations

Question 67

What are prospective payment systems?

Answer 67

Payment amounts are determined in advance, maximums allowed are preset for services.

Question 68

Define IPPS

Answer 68

Inpatient Prospective payment System

Question 69

What is IPPS?

Answer 69

Reimbursement for impatient services determined prospectively based on diagnostic related groups, and their weights.

Question 70

Define OPPS

Answer 70

Outpatient Prospective Payment System

Question 71

What is OPPS.

Answer 71

Services have clinical resource utilization, payment is based on APC and its relative weight.

Question 72

What is the future of RC?

Answer 72

Reimbursement based on outcomes, Accountable Care organizations.