True
True or False: The national health service (Beveridge) model is different from the social insurance (Bismark) model because the Beveridge model is financed by general revenue funds from fiscal taxes, whereas the Bismarck model is financed by workers' and
Its large size, complexity, intricate payment methods and rules, and programs' broad scopes
What are the four characteristics of the US healthcare sector?
False
True of False: The federal role in the healthcare sector is limited to paying providers for the healthcare costs of senior citizens.
Premiums in return for assuming the insureds' exposure to risk or loss
What do insurers receive in return for assuming the insureds' exposure to risk or loss?
The pool is large enough to pay losses of the entire group
Insurers pool premium payments for all the insureds in a group, then use actuarial data to calculate the group's premiums so that:
Texas in 1929 for Blue Cross Blue Shield
Where and when did health insurance become established in the United States?
individual or single-coverage
What is the term for health insurance that only covers the employee?
reimbursement
What term in healthcare means compensation or repayment for rendering healthcare services?
payer
Who is the third party in healthcare situations?
self insured plan
All of the following are types of episode-of-care reimbursement except:
resource based relative value scale (RBRVS)
What discounted fee schedule does Medicare use to reimburse physicians?
Global surgical package, including the procedure, local/topical anesthesia, preoperative visit, and postoperative care/follow-up; special-procedure package, including costs associated with a diagnostic or therapeutic procedure; ambulatory-visit package, i
Name and describe some versions of the global payment method.
private health insurance model
Which one of the three models of healthcare delivery is used in the United States?
The federal Medicare program is the largest single payer for health services. Medicare also "provides significant funds for medical education, research, and the care of disadvantaged and vulnerable people". In addition, Medicaid, a state-federal program,
Why is the US federal government a dominant player in the healthcare situations?
The first party is the patient himself or herself or the person, such as a parent, responsible for the patient's health bill. The second party is the physician, clinic, hospital, nursing home, or other healthcare entity rendering the care. Second parties
Who are the first, second, and third parties in healthcare situations?
UCR is defined as usual in the provider's practice, customary in the community, and reasonable for the situation. CPR is defined as customary in the providers' practice, prevailing in the community, and reasonable as the providers' lowest actual charge. P
Compare the UCR and CPR payment systems.
To reduce the costs of healthcare for which the third-party payer must reimburse the providers and to ensure continuing quality of care.
Describe the two purposes of managed care.
To control risks by knowing costs ahead of time.
Why have many insurers replaced retrospective health insurance plans with group plans such as HMOs and PPOs?
The third-party payer has no uncertainty and that the provider has a guaranteed customer base. The third-party payer knows exactly what the costs of healthcare for the group will be, and the providers know that they will have a certain group of customers.
What are advantages of capitated payments for providers and payers?
By using historical data. To establish an inpatient per diem, the total costs for all inpatient services for a population during a period are divided by the sum of the lengths of stay in the period. To determine the payment, the per diem rate is multiplie
How do third-party payers set per diem payment rates?
It is an attempt to correct perceived faults in the fee-for-service reimbursement; it controls costs on a grand or systematic scale. Some note that the episode-of-care reimbursement method creates incentives to substitute less expensive diagnostic and the
Describe the major benefits of episode-of-care reimbursement according to its advocates, as well as the major concerns about episode-of-care reimbursement expressed by its critics.
Because money is a limited source. As spending on healthcare increases, the money available for other sectors of the economy, such as education or roads, decreases. It negatively affects the country's economy and thereby its people.
Why is the constant trend of increased national spending on healthcare a concern?
episode-of-care
The financial manager of a physician group practice explained that the healthcare insurance company would be reimbursing the practice for its treatment of the exacerbation of congestive heart failure that Mrs. Zale experienced. The exacerbation, treatment
retrospective payment
In which type of reimbursement methodology do healthcare insurance companies reimburse providers after the costs have been incurred?
Reduction of a person's or a group's exposure to risk for unknown healthcare costs by the assumption of that risk by an entity
In the United States, what is healthcare insurance?
fee
In the healthcare industry, what is another term for "charge"?
Provider of care or services
There are 3 parties in healthcare reimbursement. Who is the second party?
capitated payment
Which type of reimbursement methodology is associated with the abbreviation "PMPM"?
Seniors, people with disabilities, and people with end-stage renal disease, Low income persons on state Medicaid, Active-duty and retired military personnel and their families and veterans, and native americans
The federal government funds significant portions of which groups' healthcare?
fee-for-service reimbursement
In which type of healthcare payment method does the healthcare plan pay for each service that a provider renders?
charge
In the healthcare industry, what is another term for "fee"?
case-based
From the patient's healthcare insurance plan, the rehabilitation facility received a fixed, pre-established payment for the patient rehabilitation after a total knee replacement. What type of healthcare payment method was the patient's healthcare insuranc
Fixed rate for each day a covered member is hospitalized
Which statement describes the per diem payment method?
usual Customary and Reasonable
In the healthcare insurance sector, what does UCR stand for?
patient or guarantor
There are 3 parties in healthcare reimbursement. Who is the first party?
F
T or F: The 1st party when referring to healthcare finances is always the patient
To assure that the pool is large enough to pay losses of the entire group
Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to calculate the group's premiums?
self-insured plan
All of the following methods are types of episode-of-care reimbursement EXCEPT:
managed care
Which of the following is NOT an episode-of-care reimbursement methodology?
charge.
The bill that the pathologist's office submitted for a laboratory test was $54.00. In its payment notice (remittance advice), the healthcare plan lists its payment for the laboratory test as $28.00. What does the amount of $54.00 represent?
global payment
Medicare's payment system for home health services consolidates all types of services, such as speech, physical, and occupational therapy, into a single lump sum payment. What type of healthcare payment method does this lump sum payment represent?
payer.
There are 3 parties in healthcare reimbursement. Who is the third party?
fee schedule
What is the term for a predetermined list of charges?
claim
A physician's office sent a request for payment to State Farm Insurance Company. The term used in the healthcare industry for this request for payment is a(n):
HIPAA
The code sets to be used for healthcare services reporting by both public and private insurers were designated by what legislation?
category
The first three characters in an ICD-10-CM diagnosis code represent its:
NCHS and CMS
What organizations maintain the ICD-10-CM/PCS code set?
ICD-10-CM guidelines are published for download from the NCHS website. The guidelines for ICD-10-PCS are available for download on the CMS website. Additional guidance and advice is available in Coding Clinic for ICD-10-CM and ICD-10-PCS.
Where are the ICD-10-CM/PCS coding guidelines published?
CPT
What code set was incorporated into the Healthcare Common Procedure Coding System as HCPCS Level I?
abuse
The new coding assistant at the Glen Ellyn Medical Group office coded and submitted a claim to Blue Cross for an initial evaluation and management office visit when, in fact, the patient was established with the practice and was seen strictly for a follow
TEFRA of 1982
All of the following are efforts to fight healthcare fraud and abuse except:
IPERA and IPERIA
What legislation supports the CERT program?
Unlike other improper payment review entities, recovery auditors are reimbursed via a contingency fee based on the amount of improper payments identified and successfully collected.
What differentiates recovery auditors from other entities performing improper payment reviews?
Policies and procedures, education and training, and auditing and monitoring.
What are the core areas of the coding compliance plan?
ICD
Diagnoses and inpatient procedures
HCPCS Level II
Medical and surgical supplies
.CPT
Physician inpatient or outpatient procedures
refiling claims after denials
Common forms of fraud and abuse include all of the following except:
F.
T. or F.: The CERT program was established to correct improper payments.
The recovery auditors started the program by reviewing short-stay inpatient hospital claims for specified MS-DRGs. It revealed that more than 58% of the reviewed claims were improperly billed. The improper billing resulted in $22.3 million in saving to th
Describe the importance of the RAC prepayment review demonstration project.
DHHS has released several versions of "Compliance Program Guidance" for various healthcare settings.
What resource can managers use to discover current target areas of compliance?
internal and external
What two forms of benchmarking can be used to determine a staff's level of compliance?
False.
True. or False.: The ICD is maintained by the American Medical Association.
Billing for a service not furnished as represented on the claim
Which of the following is an example of fraud?
semi-automated
Which type of RAC review combines data analysis and submission of medical records to the RAC?
none of the above
Which of the following entities does not perform improper payment reviews for CMS?
AMA
CPT is published by:
Help a manager determine a staff's level of coding compliance
Internal and external benchmarking can:
A healthcare provider unknowingly or unintentionally submits an inaccurate claim
Abuse occurs in Medicare billing when:
Operation Restore Trust
Which governmental fraud and abuse effort targeted 5 states and made a major push for accurate coding and billing. They recovered $188 million during the the1st 2 years and paved the way for implementation of a national toll free fraud and abuse hotline.
emerging technology
CPT category III codes represent:
12345
Which of the following is a correct format for a CPT code Category 1?
RACs are reimbursed on a contingency-based system, RACs are charged with finding overpayment and underpayments, RACs audit inpatient and outpatient claims
Recovery Audit Contractors are different from other improper payment review contractors because:
OIG
Who released the 7 elements to serve as an effective corporate compliance plan?
making sure coding salaries are competitive
Which of the following would NOT be part of a coding compliance plan?
5
The RAC appeals process has _________ levels.
recovery audit contractors
Which of the following is charged with identifying underpayments and overpayments for Medicare?
There is an intentional representation that an individual knows to be false, knowing that the representation could result in some unauthorized benefit to him/her or some other person
Fraud occurs in Medicare billing when:
coding clinic
The publication for coding guidelines and advice in ICD-10-CM and PCS is:
Coding medical records without complete documentation, upcoding, Correct use of encoding software
The policies and procedures section of a Coding Compliance Plan should include:
CPT.
Which of the following coding systems was created for reporting procedures and services performed by physicians in clinical practice?
Improper Payments Information Act of 2002
PERM and CERT were created under which act and its ammendments?
cpt assistant.
The publication for coding issues and guidance in CPT coding is:
Makes it lower than warranted by the actual service/resource intensity of the facility
The practice of undercoding can affect a hospital's MS-DRG case-mix in which of the following ways?
its security and privacy provisions
The Health Insurance Portability and Accountability Act of 1996 is widely known for:
implementation of a documentation improvement program
Which of the following is NOT a common cause of improper payments?
A1234
Which of the following is the correct format for HCPCS Level II codes?
Fa
Tr or Fa: When people purchase healthcare insurance for themselves and their dependents, they are purchasing single coverage.
Tr
Tr or Fa: In terms of healthcare insurance coverage, both children and spouses may be considered dependents.
Large-employer pools are the type of risk pool with the greatest diversity and the greatest ability to balance risks.
In the healthcare insurance sector, which type or risk pool has the greatest diversity and the greatest ability to balance risks?
F..
T.. or F..: Individual (private) healthcare insurance is the most common means of coverage for the nonelderly in the United States.
Blue Cross and Blue Shield, and it is one of the most influential organizations in the healthcare sector because the Blue Companies insure nearly one in three Americans.
What organization is one of the most influential in the healthcare sector? Why?
A healthcare plan offering dependent coverage includes benefits for legally married spouses, children, and young adults until they reach the age of 26, and dependents of the insured individual who have disabilities.
Who is included in a healthcare insurance policy offering dependent healthcare coverage?
Comprehensive policies and essential benefits policies provide coverage for most healthcare services but may have deductibles that must be met before the insurance company pays expenses, and the insured must also pay cost-sharing for all covered expenses
Which two types of policies offer the widest ranging coverage but require the insured to pay coinsurance until the maximum out-of-pocket costs are met?
geographic plan
Which of the following is not a type of healthcare policy limitation?
generic
Which type of prescription drug, generic or nonformulary, is less costly for insureds using their drug benefit?
Outpatient surgeries; diagnostic, interventional, and therapeutic outpatient procedures; physical, occupational, and speech therapies; mental health and dependency care; inpatient care, including surgery, home health, private nurses, and nursing homes; an
Describe the types of procedures and services that typically require prior approval.
A dependent child's primary insurer is the insurance of the parent whose birthday comes first in the calendar year. ("birthday rule")
Both parents carried healthcare insurance with dependent coverage through their employers. What procedure is used to determine which healthcare insurer is responsible for their child's health expenses?
guarantor
When a patient's healthcare services are covered under a voluntary healthcare insurance plan, who pays the remainder of a healthcare bill after the healthcare insurance company has paid?
f
t or f: The patient and the guarantor are always the same person.
group
What is the term for the number that identifies the employer, association, or other entity purchasing the healthcare insurance and indicates a common set of healthcare benefits?
f.
t. or f.: The actual charge is the same as the allowable charge.
adjustment or write-off
What is the term for the difference between the provider's actual charge and the allowable charge?
t
t or f: Copayments are cost-sharing provisions of policies that require insureds to pay a flat fee to healthcare service providers and suppliers.
false
true or false: Out-of-pocket costs for subscribers and patients are decreasing.
true
true or false: Both parents of a dependent child had employer-based group health insurance. Per the "birthday rule," the primary payer for the dependent child is the insurance of the parent whose birthday comes first in the calendar year.
greater benefits for lower premiums
Which of the following characteristics is the greatest advantage of group healthcare insurance?
t.
t. or f.: Providers' reimbursement is faster and more accurate when they submit clean claims to third-party payers than when they submit dirty claims.
the stop-loss benefit
The amount during a timeframe beyond which all covered healthcare services for an insured or dependent are paid 100 percent by the insurance plan is:
comprehensive
Which type of healthcare insurance policy offers the widest ranging coverage but requires the insured to pay coinsurance until the maximum out-of-pocket costs are met?
rider
In the healthcare industry all of the following benefits terms mean the amount during a timeframe beyond which all covered healthcare services for an insured or dependent are paid 100 percent by the insurance plan EXCEPT:
explanation of benefits
In the healthcare industry, what is the term for the written report that insurers use to notify insureds about the extent of payments made on a claim?
copayment
In the healthcare sector, what is the term for the fixed dollar amount that the guarantor pays?
prudent layperson standard
Laws passed by many states that directed healthcare companies to base decisions to pay on symptoms at the time and not diagnosis after tests is called:
long-term or extended care insurance
Which type of healthcare insurance policy provides benefits to a resident requiring nursing home care and services?
tr
tr or fa: In the healthcare sector, when a patient's healthcare services are covered under a voluntary healthcare insurance plan, the person who pays the remainder of a healthcare bill, after the healthcare insurance company has paid, is called the guaran
Spouse, natural child age 12, adopted child age 8m and 6-month infant in waiting period
The worker had group healthcare insurance coverage through her employer. The worker's household included her spouse, two natural children (ages 28 and 12), an adopted child (age 8), a 6-month infant in the waiting period prior to adoption, and the worker'
preferred generic
Which types of prescription drug is the LEAST costly for insureds using their drug benefit?
illness
All of the following phenomena are considered "life events" EXCEPT:
formulary
Which of the following is a limitation in insurance?
emergency care under the prudent layperson standard
All of the following phenomena are typical exclusions found in insurance plan riders EXCEPT:
T
T or F: In private or commercial healthcare insurance plans, covered conditions are patient conditions, diseases, or injuries for which the healthcare plan will pay and, correspondingly, covered services are services related to treating the covered condit
a write-off
Which of the following does a policyholder Not pay?
for-profit in the private sector
Which of the following characteristics is representative of commercial healthcare insurances?
disability income protection insurance
Which type of healthcare insurance policy provides benefits to a homeowner who requires an 8-month recuperation after a fall down her basement stairs?
employer-based healthcare insurance plan
Which of the following entities is also known as a "group plan"?
BCBSA
What healthcare organization is one of the most influential in the healthcare sector because it insures nearly one in three Americans?
Medicare
All of the following entities are voluntary healthcare insurance EXCEPT:
benefit
All of the following are cost-sharing provisions EXCEPT:
coinsurance
In regards to health insurance, the percentage that the guarantor pays is called the:
policy
What is the term for the contract between the healthcare insurance company and the individual or group for whom the company is assuming the risk?
Medigap
Which type of healthcare insurance policy provides benefits to pay for Medicare deductibles and coinsurance?
a risk pool
A group of individual entities whose healthcare costs are combined for evaluating financial history and estimating future costs is:
fa
tr or fa: The female worker was just married on July 1, 2016. She had worked for the organization for the past 8 years and has been covered under its group healthcare insurance policy during the entire period. She is ONLY allowed to add her new spouse dur
false.
true. or false.: Blue Cross and Blue Shield plans are all not for profit.
Being an inpatietn when being an outpatient would have had the same outcome
Potential moral hazards in consumer driven healthcare plans would be:
accidental death and dismemberment insurance
Which type of healthcare insurance policy provides benefits to an insured who is blinded as the result of an accident?
cost sharing
Co-insurance and co-payments are types of:
guarantor.
Under a voluntary healthcare insurance plan, who pays the remainder of a healthcare bill after the insurance company pays?
geographic plan.
All of the following specifications are types of limitations on healthcare policies EXCEPT:
write off
From a remittance advice, providers can determine how much money they can:
waiting period
A period of time that must pass before coverage for and employee or dependent who is otherwise eligible to enroll under the terms of a group health plan can become effective is called: