Healthcare Reimbursement -Study Guide Newest 2026
Questions and Correct Detailed Answers Already
Graded A+
Dayna is analyst at Community Hospital. She is examining inpatient cases for the
payer Super Payer. She notices that all pneumonia cases have the reimbursement
amount of $4,000 and that all CHF cases have a reimbursement rate of $4,200.
The reimbursement is consistent for the entire year. Which reimbursement
methodology is Super Payer using to reimbursement Community Hospital for
inpatient admissions? - CORRECT ANSWER-Case-rate methodology
Dr. McGee is a primary care physician. Several of Dr. McGee's patients are insured
by Super Payer. Super Payer reimburses Dr. McGee for each service she provides
during a clinic visit. Which reimbursement methodology does Super Payer use to
reimburse Dr. McGee? - CORRECT ANSWER-Fee schedule
Dr. Ward is an endocrinologist who is part of the City Endocrinologist Specialists
practice. Super Payer reimburses City Endocrinologist Specialists $450 per month
for each of the 250 beneficiaries assigned to their care. Which type of
reimbursement methodology is Super Payer using to reimburse City
Endocrinologist Specialists? - CORRECT ANSWER-Capitation
,Dr. Jones is a podiatrist who performs over 100 bunionectomies a year. Several of
Dr. Jones' patients are insured by Super Payer. Super Payer reimburses Dr. Jones
one amount for the preoperative visit, the surgery, and routine post-operative
follow-up visits. Which reimbursement methodology does Super Payer use to
reimburse Dr. Jones? - CORRECT ANSWER-Global payment method
Which of the following statements about retrospective reimbursement is false? -
CORRECT ANSWER-The fewer services performed the greater the potential for
increased total reimbursement
Giant ACO has agreed to a shared savings rate of 65 percent and a shared loss
rate of 40 percent with CMS. Giant ACO participates in a __________ risk
agreement. - CORRECT ANSWER-Two-sided
In the CMS ACO model, what is attribution? - CORRECT ANSWER-A beneficiary
is assigned to a particular ACO.
In the CMS-HCC model, beneficiaries with a risk score greater than 1 have
___________? - CORRECT ANSWER-A higher expected cost of care than the
average Medicare beneficiary
,The CMS-HCC model uses ___________ and __________ to predict the patient's
healthcare costs. - CORRECT ANSWER-Patient demographic characteristics;
health status
The pathologist's office submitted a $54 bill for a laboratory test. In its payment
notice (remittance advice), the healthcare plan lists its payment for the laboratory
test as $28. What does the amount of $54 represent? - CORRECT ANSWER-
Billed charges
Patient 62316 is admitted as an inpatient for hip replacement following a fall on
ice in the school parking lot where he works as a teacher. During his admission,
the patient received OT services post-surgery. The LOS was six days. The charges
for the encounter are $135,000. Which payer will reimburse the hospital the
highest amount? - CORRECT ANSWER-There is not enough information in the
contract matrix to determine reimbursement for this encounter.
Patient 24571 is seen in the Occupational Therapy (OT) clinic for an initial
evaluation of her carpal tunnel surgery recovery. The charges for the visit total
$150. Which payer will reimburse the facility the highest amount? - CORRECT
ANSWER-Payer B
, Patient 89423 is seen in the outpatient clinic at Happy Hospital for a pneumonia
follow-up visit. The charges for the encounter total $135. Which payer will
reimburse the hospital the lowest amount? - CORRECT ANSWER-Payer D
Patient 72341 is admitted as an inpatient for delivery. Length of stay is three days.
The charges for the encounter are $10,425.00. The cost of the encounter is
$5,848.45. Which payer will reimburse the hospital the highest amount? -
CORRECT ANSWER-Payer B
CMS uses which reimbursement methodology for inpatient psychiatric facility
services payment system because a specific payment rate is established for each
day of the admission? - CORRECT ANSWER-Per diem
CMS uses this reimbursement methodology when they contract with Medicare
Advantage Payers to care for Medicare beneficiaries under Medicare Part C. -
CORRECT ANSWER-Capitation
Bundled payment - CORRECT ANSWER-In this methodology, a predetermined
payment amount is paid to the provider for all services required for a predefined
condition and time frame.
Questions and Correct Detailed Answers Already
Graded A+
Dayna is analyst at Community Hospital. She is examining inpatient cases for the
payer Super Payer. She notices that all pneumonia cases have the reimbursement
amount of $4,000 and that all CHF cases have a reimbursement rate of $4,200.
The reimbursement is consistent for the entire year. Which reimbursement
methodology is Super Payer using to reimbursement Community Hospital for
inpatient admissions? - CORRECT ANSWER-Case-rate methodology
Dr. McGee is a primary care physician. Several of Dr. McGee's patients are insured
by Super Payer. Super Payer reimburses Dr. McGee for each service she provides
during a clinic visit. Which reimbursement methodology does Super Payer use to
reimburse Dr. McGee? - CORRECT ANSWER-Fee schedule
Dr. Ward is an endocrinologist who is part of the City Endocrinologist Specialists
practice. Super Payer reimburses City Endocrinologist Specialists $450 per month
for each of the 250 beneficiaries assigned to their care. Which type of
reimbursement methodology is Super Payer using to reimburse City
Endocrinologist Specialists? - CORRECT ANSWER-Capitation
,Dr. Jones is a podiatrist who performs over 100 bunionectomies a year. Several of
Dr. Jones' patients are insured by Super Payer. Super Payer reimburses Dr. Jones
one amount for the preoperative visit, the surgery, and routine post-operative
follow-up visits. Which reimbursement methodology does Super Payer use to
reimburse Dr. Jones? - CORRECT ANSWER-Global payment method
Which of the following statements about retrospective reimbursement is false? -
CORRECT ANSWER-The fewer services performed the greater the potential for
increased total reimbursement
Giant ACO has agreed to a shared savings rate of 65 percent and a shared loss
rate of 40 percent with CMS. Giant ACO participates in a __________ risk
agreement. - CORRECT ANSWER-Two-sided
In the CMS ACO model, what is attribution? - CORRECT ANSWER-A beneficiary
is assigned to a particular ACO.
In the CMS-HCC model, beneficiaries with a risk score greater than 1 have
___________? - CORRECT ANSWER-A higher expected cost of care than the
average Medicare beneficiary
,The CMS-HCC model uses ___________ and __________ to predict the patient's
healthcare costs. - CORRECT ANSWER-Patient demographic characteristics;
health status
The pathologist's office submitted a $54 bill for a laboratory test. In its payment
notice (remittance advice), the healthcare plan lists its payment for the laboratory
test as $28. What does the amount of $54 represent? - CORRECT ANSWER-
Billed charges
Patient 62316 is admitted as an inpatient for hip replacement following a fall on
ice in the school parking lot where he works as a teacher. During his admission,
the patient received OT services post-surgery. The LOS was six days. The charges
for the encounter are $135,000. Which payer will reimburse the hospital the
highest amount? - CORRECT ANSWER-There is not enough information in the
contract matrix to determine reimbursement for this encounter.
Patient 24571 is seen in the Occupational Therapy (OT) clinic for an initial
evaluation of her carpal tunnel surgery recovery. The charges for the visit total
$150. Which payer will reimburse the facility the highest amount? - CORRECT
ANSWER-Payer B
, Patient 89423 is seen in the outpatient clinic at Happy Hospital for a pneumonia
follow-up visit. The charges for the encounter total $135. Which payer will
reimburse the hospital the lowest amount? - CORRECT ANSWER-Payer D
Patient 72341 is admitted as an inpatient for delivery. Length of stay is three days.
The charges for the encounter are $10,425.00. The cost of the encounter is
$5,848.45. Which payer will reimburse the hospital the highest amount? -
CORRECT ANSWER-Payer B
CMS uses which reimbursement methodology for inpatient psychiatric facility
services payment system because a specific payment rate is established for each
day of the admission? - CORRECT ANSWER-Per diem
CMS uses this reimbursement methodology when they contract with Medicare
Advantage Payers to care for Medicare beneficiaries under Medicare Part C. -
CORRECT ANSWER-Capitation
Bundled payment - CORRECT ANSWER-In this methodology, a predetermined
payment amount is paid to the provider for all services required for a predefined
condition and time frame.
