Healthcare Reimbursement -Study guide
Questions and Answers Graded A+
Accountable care organization - Correct answer-Population based model for
healthcare
allowable charge - Correct answer-Amount the payer will reimburse providers for
the service
Attribution - Correct answer-Assignment of a beneficiary to particular organization
Billed charges - Correct answer-Amount the provider is actually charging for a
service
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.
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,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
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, $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
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
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Questions and Answers Graded A+
Accountable care organization - Correct answer-Population based model for
healthcare
allowable charge - Correct answer-Amount the payer will reimburse providers for
the service
Attribution - Correct answer-Assignment of a beneficiary to particular organization
Billed charges - Correct answer-Amount the provider is actually charging for a
service
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.
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
,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
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
, $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
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
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