HIM 130 REIMBURSEMENT QUIZZES (PRINCIPLES OF
HEALTHCARE REIMBURSEMENT TEXTBOOK) | QUESTIONS
AND ANSWERS | 2026 UPDATE | WITH COMPLETE SOLUTION
Which one of the three models of healthcare delivery is used in the US?
Answer - The private health insurance model is used in the United States.
Why is the US federal government a dominant player in the healthcare sector?
Answer - The federal government is a dominant player in the healthcare sector
because its Medicare program is the largest single payer for health services.
The federal government engages in demonstration projects aimed at advancing
healthcare reimbursement methodologies. The federal government funds
these projects and then selects the best performing models for
implementation. Other payers tend to follow their lead and adopt new
methods and models for reimbursement in the commercial sector.
Who are the first, second, and third parties in healthcare situations? Answer -
The first party is the patient, the second party is the healthcare entity providing
care, and the third party is the insurance company or health agency that pays
the second party provider.
What are the two types of healthcare reimbursement methodologies? Answer
- Retrospective and prospective
How do third-party payers set per diem payments rates? Answer - Third party
payers use historical data such as dividing total costs for all prior inpatients by
their LOS
,Why have many insurers replaced retrospective reimbursement methods with
prospective payment methods? Answer - In retrospective payment methods,
the insurer learns of the costs of health services after providers give patients
care, and the third-party payer has a greater financial risk than the provider. To
control financial risk, insurers have replaced retrospective with prospective
payment systems. In prospective payment systems, a greater portion of the risk
is shifted to the provider's side.
What are advantages of capitated payments for providers and payers? Answer -
The advantage of capitated payment for providers is having a guaranteed
customer base for a practice or facility. The advantage for third party payers is
knowing the cost of reimbursable services.
How does case-rate methodology incentivize healthcare entities to provide
efficient care? Answer - The case rates are fixed for a specified episode of care.
The payment rate does not change based on LOS or total charges for the
encounter. The case rate provides incentive to provide efficient care because
the healthcare entity will experience a profit or loss based on the total cost for
the encounter.
Describe the major benefits of prospective reimbursement according to its
advocates, as well as the major concerns about prospective reimbursement
expressed by its critics. Answer - Advocates say that episode-of-care
reimbursement rewards effective and efficient provision of healthcare services
by enabling such providers to make money from their streamlined services.
Critics say that the system creates incentives to substitute cheaper diagnostic
and therapeutic tests and services and to delay or deny treatment.
Why is the constant trend of increased national spending on healthcare a
concern? Answer - This increased spending is a concern because money is a
limited resource. As spending on healthcare increases, the money available for
other sectors of the economy decreases.
, ICD Answer - Diagnoses and inpatient procedures
HCPCS Level II Answer - Medical and Surgical Supplies
CPT Answer - Physician inpatient or outpatient procedures
Common forms of fraud and abuse include all of the following except: Answer -
Refiling claims after denials
Name and describe three of the seven OIG elements of an effective compliance
plan. Answer - The seven elements are: written policies and procedures,
designation of a compliance officer, education and training, communication,
auditing and monitoring, disciplinary action, and corrective action.
The CERT program was established to correct improper payments. Answer -
False
Discuss why the National Recovery Audit Program was established. Answer -
The purpose of National Recovery Audit Program is to prevent future improper
payments. The program recovers improper payments on behalf of CMS. In
exchange for identifying improper payments, the RACs receive a contingency
fee for each recovered improper payment.
What resource can managers use to discover current hot areas of compliance?
Answer - The OIG Workplan, revised annually
What two forms of benchmarking can be used to determine a staff's level of
compliance? Answer - Internal and external
HEALTHCARE REIMBURSEMENT TEXTBOOK) | QUESTIONS
AND ANSWERS | 2026 UPDATE | WITH COMPLETE SOLUTION
Which one of the three models of healthcare delivery is used in the US?
Answer - The private health insurance model is used in the United States.
Why is the US federal government a dominant player in the healthcare sector?
Answer - The federal government is a dominant player in the healthcare sector
because its Medicare program is the largest single payer for health services.
The federal government engages in demonstration projects aimed at advancing
healthcare reimbursement methodologies. The federal government funds
these projects and then selects the best performing models for
implementation. Other payers tend to follow their lead and adopt new
methods and models for reimbursement in the commercial sector.
Who are the first, second, and third parties in healthcare situations? Answer -
The first party is the patient, the second party is the healthcare entity providing
care, and the third party is the insurance company or health agency that pays
the second party provider.
What are the two types of healthcare reimbursement methodologies? Answer
- Retrospective and prospective
How do third-party payers set per diem payments rates? Answer - Third party
payers use historical data such as dividing total costs for all prior inpatients by
their LOS
,Why have many insurers replaced retrospective reimbursement methods with
prospective payment methods? Answer - In retrospective payment methods,
the insurer learns of the costs of health services after providers give patients
care, and the third-party payer has a greater financial risk than the provider. To
control financial risk, insurers have replaced retrospective with prospective
payment systems. In prospective payment systems, a greater portion of the risk
is shifted to the provider's side.
What are advantages of capitated payments for providers and payers? Answer -
The advantage of capitated payment for providers is having a guaranteed
customer base for a practice or facility. The advantage for third party payers is
knowing the cost of reimbursable services.
How does case-rate methodology incentivize healthcare entities to provide
efficient care? Answer - The case rates are fixed for a specified episode of care.
The payment rate does not change based on LOS or total charges for the
encounter. The case rate provides incentive to provide efficient care because
the healthcare entity will experience a profit or loss based on the total cost for
the encounter.
Describe the major benefits of prospective reimbursement according to its
advocates, as well as the major concerns about prospective reimbursement
expressed by its critics. Answer - Advocates say that episode-of-care
reimbursement rewards effective and efficient provision of healthcare services
by enabling such providers to make money from their streamlined services.
Critics say that the system creates incentives to substitute cheaper diagnostic
and therapeutic tests and services and to delay or deny treatment.
Why is the constant trend of increased national spending on healthcare a
concern? Answer - This increased spending is a concern because money is a
limited resource. As spending on healthcare increases, the money available for
other sectors of the economy decreases.
, ICD Answer - Diagnoses and inpatient procedures
HCPCS Level II Answer - Medical and Surgical Supplies
CPT Answer - Physician inpatient or outpatient procedures
Common forms of fraud and abuse include all of the following except: Answer -
Refiling claims after denials
Name and describe three of the seven OIG elements of an effective compliance
plan. Answer - The seven elements are: written policies and procedures,
designation of a compliance officer, education and training, communication,
auditing and monitoring, disciplinary action, and corrective action.
The CERT program was established to correct improper payments. Answer -
False
Discuss why the National Recovery Audit Program was established. Answer -
The purpose of National Recovery Audit Program is to prevent future improper
payments. The program recovers improper payments on behalf of CMS. In
exchange for identifying improper payments, the RACs receive a contingency
fee for each recovered improper payment.
What resource can managers use to discover current hot areas of compliance?
Answer - The OIG Workplan, revised annually
What two forms of benchmarking can be used to determine a staff's level of
compliance? Answer - Internal and external
