HIM 130 REIMBURSEMENT EXAM
QUESTIONS AND ANSWERS GRADED A+
2026
Which one of the three models of healthcare delivery is used in the US? - ANS The private
health insurance model is used in the United States.
Why is the US federal government a dominant player in the healthcare sector? - ANS 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? - ANS 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? - ANS Retrospective
and prospective
How do third-party payers set per diem payments rates? - ANS Third party payers use
historical data such as dividing total costs for all prior inpatients by their LOS
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 1
, Why have many insurers replaced retrospective reimbursement methods with prospective
payment methods? - ANS 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? - ANS 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? -
ANS 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. -
ANS 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? -
ANS 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 - ANS Diagnoses and inpatient procedures
HCPCS Level II - ANS Medical and Surgical Supplies
CPT - ANS Physician inpatient or outpatient procedures
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 2
QUESTIONS AND ANSWERS GRADED A+
2026
Which one of the three models of healthcare delivery is used in the US? - ANS The private
health insurance model is used in the United States.
Why is the US federal government a dominant player in the healthcare sector? - ANS 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? - ANS 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? - ANS Retrospective
and prospective
How do third-party payers set per diem payments rates? - ANS Third party payers use
historical data such as dividing total costs for all prior inpatients by their LOS
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 1
, Why have many insurers replaced retrospective reimbursement methods with prospective
payment methods? - ANS 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? - ANS 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? -
ANS 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. -
ANS 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? -
ANS 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 - ANS Diagnoses and inpatient procedures
HCPCS Level II - ANS Medical and Surgical Supplies
CPT - ANS Physician inpatient or outpatient procedures
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 2
