HITT 2335 FINAL EXAM QUESTIONS WITH
ACCURATE ANSWERS
Claim - ANSWER Request for payment of healthcare services
Retrospective payment system - ANSWER Type of fee-for-service reimbursement in
which providers receive compensation after health services have been rendered
Prospective Payment System (PPS) - ANSWER A method of reimbursement in which
third party payment is made based on a predetermined, fixed amount, and classification
of the type of service
Episode of care reimbursement method - ANSWER lump-sum payment to provider to
compensate them for all the healthcare services delivered to a patient for a specific
illness and/or over a specific period of time. EOC reimbursement methods include
capitated payments, global payments, Medicare, ambulatory surgery center, and
Medicare PPS
Fee-for-service reimbursement method (FFS) - ANSWER Type of retrospective payment
mechanism where separate fee is paid for each service renedered such as: lab tests,
examinations, consultation, office visit, intravenous fluid, or other service or supply
provided
Reimbursement - ANSWER Is the amount collected by the facility for the services it bills
Charges - ANSWER The amount the facility actually bills for services it provides
Self-pay - ANSWER a patient with no health insurance who must pay out of pocket for
medical care or who chooses to pay and then collect from the insurance company
What target should be the focus of a pay-for-performance system? - ANSWER Which
, valid and reliable performance measures are available
Capitation - ANSWER A common method of reimbursement used primarily by health
maintenance organizations in which the provider or medical facility is paid a fixed, per
capita amount for each individual enrolled in the plan, regardless of how many or few
services the patient uses
Managed care - ANSWER Payment method in which the third party payer has
implemented some provisions to control the costs of healthcare while maintaining
quality care. Systematic merger of clinical, financial, and administrative processes to
manage access, cost and quality of healthcare
Global payment - ANSWER Method of payment in which the 3rd party payer makes one
consolidated payment to cover the services of multiple providers who are treating a
single episode of care
Which codes are used to report physician services in the clinical setting? - ANSWER
CPT codes
What are some examples that influence a facility's DRG case mix? - ANSWER • There
should be a manageable number of DRG's which encompass all patients seen on an
inpatient basis.
• Each DRG should contain patients with a similar pattern of resource intensity.
• Each class should be clinically coherent
How does undercoding effect a facilities reimbursement? - ANSWER Makes it lower than
warranted by the actual service/resource intensity of the facility
How does upcoding affect a facilities reimbursement? - ANSWER The fraudulent
process of submitting codes for reimbursement that indicates more complex or
higher-paying services than those that the patient actually received
Example of voluntary healthcare insurance? - ANSWER • Private or commercial
ACCURATE ANSWERS
Claim - ANSWER Request for payment of healthcare services
Retrospective payment system - ANSWER Type of fee-for-service reimbursement in
which providers receive compensation after health services have been rendered
Prospective Payment System (PPS) - ANSWER A method of reimbursement in which
third party payment is made based on a predetermined, fixed amount, and classification
of the type of service
Episode of care reimbursement method - ANSWER lump-sum payment to provider to
compensate them for all the healthcare services delivered to a patient for a specific
illness and/or over a specific period of time. EOC reimbursement methods include
capitated payments, global payments, Medicare, ambulatory surgery center, and
Medicare PPS
Fee-for-service reimbursement method (FFS) - ANSWER Type of retrospective payment
mechanism where separate fee is paid for each service renedered such as: lab tests,
examinations, consultation, office visit, intravenous fluid, or other service or supply
provided
Reimbursement - ANSWER Is the amount collected by the facility for the services it bills
Charges - ANSWER The amount the facility actually bills for services it provides
Self-pay - ANSWER a patient with no health insurance who must pay out of pocket for
medical care or who chooses to pay and then collect from the insurance company
What target should be the focus of a pay-for-performance system? - ANSWER Which
, valid and reliable performance measures are available
Capitation - ANSWER A common method of reimbursement used primarily by health
maintenance organizations in which the provider or medical facility is paid a fixed, per
capita amount for each individual enrolled in the plan, regardless of how many or few
services the patient uses
Managed care - ANSWER Payment method in which the third party payer has
implemented some provisions to control the costs of healthcare while maintaining
quality care. Systematic merger of clinical, financial, and administrative processes to
manage access, cost and quality of healthcare
Global payment - ANSWER Method of payment in which the 3rd party payer makes one
consolidated payment to cover the services of multiple providers who are treating a
single episode of care
Which codes are used to report physician services in the clinical setting? - ANSWER
CPT codes
What are some examples that influence a facility's DRG case mix? - ANSWER • There
should be a manageable number of DRG's which encompass all patients seen on an
inpatient basis.
• Each DRG should contain patients with a similar pattern of resource intensity.
• Each class should be clinically coherent
How does undercoding effect a facilities reimbursement? - ANSWER Makes it lower than
warranted by the actual service/resource intensity of the facility
How does upcoding affect a facilities reimbursement? - ANSWER The fraudulent
process of submitting codes for reimbursement that indicates more complex or
higher-paying services than those that the patient actually received
Example of voluntary healthcare insurance? - ANSWER • Private or commercial
