HIM 130 REIMBURSEMENT QUIZZES (PRINCIPLES
OF HEALTHCARE REIMBURSEMENT TEXTBOOK)
COMPLETE QUESTIONS WITH 100% VERIFIED
ANSWERS
\.Which one of the three models of healthcare delivery is used in the US? - ANSWERS✔-The
private health insurance model is used in the United States.
\.Why is the US federal government a dominant player in the healthcare sector? - ANSWERS✔-
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? - ANSWERS✔-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? - ANSWERS✔-
Retrospective and prospective
\.How do third-party payers set per diem payments rates? - ANSWERS✔-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? - ANSWERS✔-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? - ANSWERS✔-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? -
ANSWERS✔-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. - ANSWERS✔-
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? -
ANSWERS✔-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 - ANSWERS✔-Diagnoses and inpatient procedures
, \.HCPCS Level II - ANSWERS✔-Medical and Surgical Supplies
\.CPT - ANSWERS✔-Physician inpatient or outpatient procedures
\.Common forms of fraud and abuse include all of the following except: - ANSWERS✔-Refiling
claims after denials
\.Name and describe three of the seven OIG elements of an effective compliance plan. -
ANSWERS✔-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. - ANSWERS✔-False
\.Discuss why the National Recovery Audit Program was established. - ANSWERS✔-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? - ANSWERS✔-
The OIG Workplan, revised annually
\.What two forms of benchmarking can be used to determine a staff's level of compliance? -
ANSWERS✔-Internal and external
\.The International Classification of Diseases (ICD) is maintained by the American Medical
Association. - ANSWERS✔-False
OF HEALTHCARE REIMBURSEMENT TEXTBOOK)
COMPLETE QUESTIONS WITH 100% VERIFIED
ANSWERS
\.Which one of the three models of healthcare delivery is used in the US? - ANSWERS✔-The
private health insurance model is used in the United States.
\.Why is the US federal government a dominant player in the healthcare sector? - ANSWERS✔-
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? - ANSWERS✔-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? - ANSWERS✔-
Retrospective and prospective
\.How do third-party payers set per diem payments rates? - ANSWERS✔-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? - ANSWERS✔-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? - ANSWERS✔-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? -
ANSWERS✔-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. - ANSWERS✔-
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? -
ANSWERS✔-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 - ANSWERS✔-Diagnoses and inpatient procedures
, \.HCPCS Level II - ANSWERS✔-Medical and Surgical Supplies
\.CPT - ANSWERS✔-Physician inpatient or outpatient procedures
\.Common forms of fraud and abuse include all of the following except: - ANSWERS✔-Refiling
claims after denials
\.Name and describe three of the seven OIG elements of an effective compliance plan. -
ANSWERS✔-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. - ANSWERS✔-False
\.Discuss why the National Recovery Audit Program was established. - ANSWERS✔-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? - ANSWERS✔-
The OIG Workplan, revised annually
\.What two forms of benchmarking can be used to determine a staff's level of compliance? -
ANSWERS✔-Internal and external
\.The International Classification of Diseases (ICD) is maintained by the American Medical
Association. - ANSWERS✔-False
