payment methodologies

Question 1

T or F
Payers use a variety of methodologies to determine how much they will allow for different charges

Answer 1

True

Question 2

What is the payment method used for Medicare Inpatient services

1. MS-DRG
2. APC
3. OOPS

Answer 2

1 MS-DRG
MEDICARE SEVERITY DIAGNOSIS - RELATED GROUP

Question 3

T or F

MS-DRG’S are grouped into 20 major diagnostic categories (MDC’s)

Answer 3

False

25

Question 4

Which are not the factors of MS-DRG
1. Patient age
2. Diagnosis
3. Discharge disposition
4. Procedure to determine a payment schedule

Answer 4

3. Procedures to determine a payment rate not schedule

Question 5

MS-DRC is the not a popular today as is the past due to the the increase in the Medicaid patients.

Answer 5

False, most widely used due to growing number of Medicare patient

Question 6

T or F

CMS allows hospitals to file subsequent inpatient DRUG adjustments up to 30 days from the date of the remittance advice for Medicare beneficiaries

Answer 6

FALSE
60 day not 30

Question 8

The APC was implement as an Outpatient Prospective Payment System by the Balanced Budget act of 1996

Answer 8

False
1997

Question 9

T or F

The OPPS under the Medicaid for Hospital Outpatient services, certain Part B services furnished to hospital inpatients who hae no part A coverage and partial hospitalization services furnished by community mental health centers

Answer 9

True

Question 10

OPPS
1. Out Patient Payment System
2. Outpatient Prospective Payment System
3. Outpatient Payment Plan system

Answer 10

2. Outpatient Prospective Payment System OOPS

Question 11

T or F

all services paid under the OPPS are classified into groups called Payment Classification Group. or PCG.

Answer 11

FALSE
APC Ambulatory Payment Classifications or APC’s

Question 12

T or F

Services in each APC are grouped into similar what
1. Similar service types and resources utilized
2. Resources required and hospitalization time
3. Similar clinically and in terms of the resources they require

Answer 12

3. Similar clinically and in terms of the resources they require

Question 13

T or F

Payment rate are often the same overlapping APC codes.

Answer 13

False
payment rate is established for each APT

Question 14

Hospitals can only be paid foor one APC for a single encounter

Answer 14

FALSE
Hospitals may be paid for more than one APC depending on the servies provided for a singe encounter.

Question 15

Which not an element required to assign an APC
1. HCPCS/CPT codes
2. E&M Codes
3. Reason for VISIT ICD10 code
4. Site of service
5. Date of service

Answer 15

5 date of service

Question 16

how are the supportive ad ancillary services accomodated? select all that apply
1 Coded as secondary code
2 Coded as a seperate service
3 made by Medicare only
4 Packaged into payment for the primary service that was performed

Answer 16

4 packaged into payment for priimary services performed

Question 17

T or F

medicare will not make seperate payent for servies that are packaged and are considered an integral part of another service that was performed and paid uder the OPPS.

Answer 17

TRUE

Question 18

T or F

Medicare will only pay for an inpatient - only procedure on an outpatiend claim only if
1. Patient is hopsitalized for more than 1 day
2. Patient has a referral
3. patient dies before admission, and the COT code for the inpatient - only procedure then add a CA modifier

Answer 18

3. Patient dies and the CPT code is added for the inpatient - only procedure and then add a CA

Question 19

What units are exempt from OOPS

1. Critical access hospitals
2. Certain hospitals in Texas.
3. Cancer hospitals
4. In Indian health facilities

Answer 19

2. Certain hospitals in Maryland, not Texas.

Question 20

What units are not affected by OPPS
1. Critical care hospitals.
2. Acute care outpatient hospitals service
3. Hospital and district part hospital units exempt from inpatient PPS.
4. Partial hospitalization programs unassociated

Answer 20

4. Partial hospitalization programs ASSOCIATED

Question 21

True or false
Medicare pay some outpatient services, including laboratory screening mammograms, and outpatient physical therapy on full time schedule bases

Answer 21

Faults they pay on a fee schedule basis

Question 22

If he schedule basis is a list of what
1. CPT and HCPCS codes and what a Medicare will allow for each before deductible and coinsurance supplies
2 HCPCS and ICD 10 codes and what Medicare will allow for each after deductible and coinsurance supplies
3. HCPCS codes and what Medicare allow for each before the deductible and coincidence applies


Answer 22

1. A fee schedule lists the CPT and HCPCS codes and what Medicare allows for each before deductibles and coinsurance is applied. 

Question 23

RBRVS
1. Resource-Bias Related Value System
2. Resource-Based Relative Value System
3. Reasonable-Billing Relative Value Scale
4. Resource-Based Relative Value Scale

Answer 23

4. Resource-Based Relative Value Scale

Question 24

The Federal Government established a standardized physican payment schedule based on
1. Physican Based Relative Value Scale
2. Region Based Relative Value Scale
3. Resource-Based Relative Value Scale

Answer 24

3 resource-based relative vlaue scale

Question 25

# T or F This RBRVS does not base payment on charges for the service.

Answer 25

True It is based on the value systmen

Question 26

The RBRVS is based on 3 major elements. Which is not part of those three select all that apply 1. Fee Schedule for payment of Hospital services, based on a RVU Relative Value Unit 2. Medicaid Volume Performance Standard (MVPS) for the rates of decrease in Medicaid ependitures for Hospital Services. 3. Increases the amount non-partivcipating physicians can charge beneficiaries, referred to as the Expanding Charge. 4. All of the above 5. none of the above

Answer 26

1. Fee schedule for payment of **PHYSICIAN** Services 2. **MEDICARE** Not medicaid Valume Performance Standard for rate **increase**in **Medicare**exoedutyres for **Physician** services 3. **Limits** on the amount non-participating Physicians can charge beneficiaried referred to as the **LIMITING CHARGE**

Question 27

The Limiting charge replaced the Maximum Allowable Actual Charge, or MAAC. This Limiting charge is _____ of the fee schedule amount 1. 110% 2. 115% 3. 120% 4. 90%

Answer 27

2. 115%

Question 28

# T or F Most medical procedure recognized by Medicare has been assigned units of value for various resources used to provide the service.

Answer 28

FALSE **EVERY MEDICAL PROCEDURE RECOGNIZED BY MEDICARE HAS BEEN ASSIGNED**

Question 29

Which is not one of the three separate RVU's that are associated with the calculation of a payment under Medicare Prospective Payment System ( MPPS) 1. Work Release (Work RVU) 2. Practice Exercise (PE) 3. Malpractice Insurance Requirement (MP)

Answer 29

1. Work **Required** (Work RVU) 2. Practice **Expense** (PE) 3. Malpractice insurance **Expense** (ME)

Question 30

# T or F Medicare rates change for providers base on Malpractice Insurance expenses

Answer 30

TRUE

Question 31

# T or F Many 3rd party payers use Usual Customary and Reasonable (UCR) charges to determine the value they will pay for services.

Answer 31

True

Question 32

What does the UCR charge base its method on 1. Physician - charge data 2. Physician - charge by region/location 3. Physician - charge data accumulated over time 4. Physician - % charge for las 30 days

Answer 32

3. Physician - charge data accumulated over time

Question 33

How is the basis for UCR payments calculated 1. After ranking charges for given service from highest to lowest 2. After ranking charges for given hospital stay based on number of days admitted 3. After ranking Charges for given services from lowest to highest 4. After ranking charges for given services based on number of services performed the payer uses a specific point ie 75%, 80% as basis for UCR payments

Answer 33

3. After ranking charges for **given service from lowest to highest** the payer uses specific point relative to the % as basis for UCR payment

Question 34

Which one is not a payment methodology 1. APC 2. MS-DRG 3. OPPS 4. HCPCS

Answer 34

4 HCPCS THAT A CODE SYSTEM THESE ARE APC MS-DRG OPPS

Question 35

# Which ONE IS NOT payment methodologY 5. FEE SCHEDULE 5. RBRVS 6. ALOS 6. UCR 7. SNF PDPM

Answer 35

3. ALOS Average length of stay. Not payment methodology

Question 36

# Which is not a payment methodology 1. CAH 2. CAPITALIZATION 3. PER DIAM 4. PERCENT OF CHARGE 5. FEE - FOR - SERVICE

Answer 36

2. **CAPITATION** NOT Capitalization

Question 37

Who uses the Patient-Driven Payment Model (PDPM) 1. Rehab therapy 2. Speciality Facilities 3. SNF 4. Hospital ERs

Answer 37

3.skilled nursing facilities

Question 38

Which payment method classifies patients into payment groups based on specific data driven patient characteristics. 1. Fee Schedle 2. PDPM 3. OOPS 4. MS-DRG

Answer 38

2. PDPM

Question 39

Which payment method is used in inpatient services and groupes catagories of 25? 1. ACPC 2. PDPM 3. MS-DRG 4. RBRVS

Answer 39

3. MS-DRG

Question 40

Which model uses 6 payment components derives payment 5 are case-mix adjusted to cover SNF resources that vary according to patient characteristics, and 1 that is non-case-mix adjusted to address SNF resources that do not vary by patient 1. RBRVS 2. RVU 3. MVPS (Medicare Value Performance Standard) 4. PDPM

Answer 40

4. PDPM Patient Driven Payment Model

Question 41

# T or F Patient characteristics in the PDPM are used to assign patients into a case-mix group CMG to derive payment. Per Diem payments are adjusted to reflect varing costs through out the SNF stay.

Answer 41

TRUE

Question 42

Which Plan is much like the CPT/HCPCS codes, as they are billed with Health Insurance Prospective Payment Systems HIPPS codes.

Answer 42

The SNF claims billing PDPM

Question 43

What is not part of the 5 characteristice of the PDPM, HIPPS code 1. Patients physical Therapy components and OT components classification 2. Patients SLP component classification 3. Emergency medical Component Classification 4. Patients nursing component classification 5. patient non-therapy ancillary NTA component classification 6. Assessment indicator (AI) code

Answer 43

3. There is not emergency medical component

Question 44

whats the bed limitation for CAH? 1. 15 2. 25 3. 10 4. 30

Answer 44

2. 25

Question 45

True or False CAHs are not subject to the IPPS (Inpatient Prospective Payment System) or the OPPS.

Answer 45

TRUE

Question 46

CAH are paid for most inpatient and outpatient services at_____ of reasonable costs. 1. 95% 2. 110% 3. 101% 4. 99%

Answer 46

3. 101%

Question 47

True or False Services at CAH are not subject to Medicare A & B deductible and coinsurances.

Answer 47

False the CAH are subject to deductible and coinsurances

Question 48

CAH can have an ALOS of ___ hours or less per patient for acute care (exclude swing bed services and beds within district part units, or DPUs). 1. 36 hours 2. 48 hours 3. 76 hours 4. 96 hours

Answer 48

4. 96 hours

Question 49

CAH must be located more than _____miles drive from any hospital or CAH in CAH in an area with mountainous terrain or only secondary roads. 1. 35 miles 2. 50 miles 3. 65 miles 4. 75 miles

Answer 49

1. 35 miles

Question 50

How often are CAH required to furnish 24 hour emergency care services in a week. 1. 5/24 hours 2. 7/10 hour shifts 3. 7/24 hour

Answer 50

3. 24 hrs day for 7 days

Question 51

Which method of payment in which a provider is paid a set dollar amount for each patient for a specific time period, and that payment covers all care the group of patients receives for that period no matter the actual charges? 1. Per Diem 2. Capitation 3. PDPM 4. Fee-for Service

Answer 51

2. CAPITATION

Question 52

Which method are providers paid a predetermined amount for each day an inpatient is in the facility regardless of actual charges or costs incurred.

Question 53

T or F The Per Diem rates cannot vary based on services (for example medical-surgical, obstetrics, mental health, intensive care) or can be uniform regardless of the intensity of service.

Answer 53

FALSE This rate CAN vary based on service type.

Question 54

Which payment method uses percent of charges, the claim is paid at a predetermined percentage discount rate? 1. Per Diem 2. Capitation 3. Percentage of Charges 4. Fee-for Service

Answer 54

3. Percentage of Charges

Question 55

Which payment method is the oldest method of payment, which providers are paid for each medical services rendered to a patient. 1. Per Diem 2. Capitation 3. Percentage of Charges 4. Fee-for Service

Answer 55

4. Fee-for Services

Question 56

What is the name of the electronic file that resides in the provider's info system and that contains charges that can be posted to a patient account? Select all that apply 1. The working file 2. Chargemaster 3. Fee Schedule 4. Charge Description Master CDM 5. Item master 6. All of the above C

Answer 56

6. All of the ones listed

Question 57

Each item in the Chargemaster include which of the following? Select all that apply 1. description 2. Cost of the item 3. the ICD-10 or HCPCS codes 4. identifies the GL account it impacts. 5 When applicable it includes inventory control info 6. All the above

Answer 57

2. The PRICE of the item not the Cost 3. THE CPT OR HCPCS CODES not the ICD-10

Question 58

T or F Individual department generate charges for a patient account by using an automated cost or Order charge system or manually by paper encounter forms.

Answer 58

FALSE Individual department generate charges for a patient account by using an automated CHARGE or ORDER EMTRY SYSTEM or manually by paper encounter forms.

Question 59

T or F In most hospitals or clinics the line item chargemaster is hard-coded with ICD and HIPPA code as often as possible.

Answer 59

False It is hard coded with CPT or HCPCS codes

Question 60

Does the chargemaster include professional fee (pro fee) amounts (or calculations) and other physician billing information such as modifiers, ICD-10 codes, diagnosis flags physician group numbers..etc? Yes or NO

Answer 60

Yes it includes those fields and calculation

Question 61

Which are elements are included in the chargemaster. Select that are 1. Department numbers 2. Revenue Codes 3. Chargemaster numbers 4. charge description 5. CPT/HCPCS CODES 6. Modifiers 7. GL numbers

Answer 61

1. Department numbers 2. Revenue Codes 3. Chargemaster numbers 4. charge description 5. CPT/HCPCS CODES 6. Modifiers 7. GL numbers

Question 62

how often should the Chargemaster be reviewed to check for items that should be added or removed? 1. Every 90 days 2. Every 6 months 3. Every 12 months - yearly 4. Very 2 years

Answer 62

3. every year!

Question 63

Is it fraudulent to assign incorrect code to a charge for Medicare?

Answer 63

YES

Question 64

What is the payment plan where insurance payers will contract with providers to receive discounts off normally billed charges 1. Capitation 2. Percent of Charges 3. Insurance payer Contracts - Contracting 4. Resource-Based Relative Value Scale

Answer 64

3. insurance payer Contracts - contracting

Question 65

What are some of the elements of a payer contract? 1. Contract effective and renewal dates 2. Fee schedule terminations 3. Terminations provisions 4. Timely filing requirements 5. Refund request time allowances 6. Denial rate 7. medical policies

Answer 65

2. FEE SCHEULE REVISIONS

Question 66

What are some of the elements of a payer contract? 1. Prior auths 2. fee schedule rating 3. Reimbursement rate 4. charge % of payer mix 5. payment % of payer mix 6. Reimbursement performance 7. Credentialing 8. all of the above

Answer 66

8. all