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Terms in this set (44)What is the reimbursement methodology used in acute care inpatient setting payment system (IPPS)? Case rate Rhonda saw her nurse practitioner Ms. Jones for a sinus infection. Ms. Jones practices at Sunnyside Clinic incident to Dr. Howard. Dr. Howard is a Medicare participating physician. The MPFS amount is $38.00 for the clinic visit. How much will Sunnyside Clinic be reimbursed for Rhonda's encounter? $38.00 Rhonda saw her nurse practitioner Ms. Jones for a sinus infection. Ms. Jones practices at Sunnyside Clinic incident to Dr. Howard. Dr. Howard is a Medicare participating physician. The MPFS amount is $38.00 for the clinic visit. What is the coinsurance amount that Rhonda must pay? $7.60 Which RBRVS RVU accounts for the skill of the physician, mental effort and judgement, and psychological stress? Work Which if the following does not impact the CMG used in the SNF services payment system? Amount of therapy provided to resident Amount of therapy provided to resident Lixin is an inpatient coder at Community Hospital. He is determine the MS-DRG for a hip replacement surgery. He has determined that the encounter is surgical. What is the next step in the MS-DRG assignment process. Refinement Questions Which
classification system is used for the Hospital Outpatient system (OPPS)? APCs What is the VBP program for physicians that links payment to quality measures and cost-saving goals? Quality Payment Program (QPP) In MS-DRGs,
_____________ is a proxy for resource consumption. the relative weight Lizbeth is a Medicare beneficiary enrolled at A+ Medicare Advantage plan. Her risk score is 1.56. That means _____________. A+ Medicare Advantage will receive a higher monthly capitated payment amount for Lizbeth than the average Medicare beneficiary. Use Table 6.1 in your textbook for this question. TA Use Table 6.5 in your textbook for this question. ES1 When a third-party payer negotiates reduced fees for their beneficiaries they are using a ________________ reimbursement methodology. percent of billed charges When a third-party payer reimburses the provider a fixed, per capita amount for a specified period of time they are using a __________ reimbursement
methodology. capitated payment In the PDPM the two components adjusted for residents living with HIV/AIDs are _________ and ______________. nursing and NTA Fee schedule a predetermined list of fees that the third party payer allows for payment for a set of healthcare services. Capitation the third-party payer reimburses providers a fixed, per capita amount for a period. per capita means per head or per person Global payment the
third-party payer makes one combined payment to cover the services of multiple providers, typically physicians, who are treating a single episode of care Percent of billed charges the contracting unit is the claim. third party payers negotiate reduced fees for their members or beneficiaries to control their costs. Case Rate the third-party payer reimburses the provider one amount for the entire visit or encounter regardless of the number of services or length of the encounter Per diem a type of retrospective payment method that is commonly used in the hospital inpatient setting. the third party payer reimburses the provider a fixed rate for each day a beneficiary is
hospitalized Describe the difference between ACO models that have a 1-sided risk versus a 2-sided risk. The one-sided model allows the organization to share in cost savings. The two-sided model allows the organization to share in cost savings, but the organization must also share in the losses if the costs are greater than the benchmark amount. CMS uses the CMS-HCC model when contracting with Medicare Advantage payers. (see figure 4.4 in your textbook). Why does CMS use the CMS-HCC model to adjust capitation rates for their beneficiaries rather than using a standard capitation rate for every beneficiary? To predict which beneficiaries will be most costly to treat during the following year and then to increase capitated payments for those individuals. this allows CMS to redirect payments from managed care payers that may target healthy populations to managed care payers that provide insurance for the most ill patients. List the four steps for MS-DRG assignment. 1. Pre-MDC assignment Which reimbursement methodology is used for the SNF PPS Per diem What are the six components of care used in the PDPM model · Physical Therapy Which of these components have a variable day adjustment? PT, OT and NTA. Which of these components are adjusted for residents with HIV/AIDS? ·Nursing Classification packaging occurs when reimbursement for minor ancillary services associated with a significant procedure is combined into a single payment for the procedure. bundling occurs when payment for multiple significant procedures or multiple units of the same procedure related to an outpatient encounter or to an episode of care is combined into a single unit of payment. What are the reimbursement methodologies used in OPPS? APC, Per diem, Comprehensive APC (C-APC), Conditional APC, Composite, Packaged, fee schedule, reasonable cost, services not reimbursed under OPPS What is the classification system of OPPS? APC List the provisions of the OPPS Interrupted services Interrupted Services Reported with modifiers High Cost Outlier Cost of providing service is 1.75 times higher than APC payment and Cost must exceed APC payment plus a fixed dollar thresholdAdd on- 50% of the difference between the cost and 1.75 times the APC payment Rural Hospital adjustment - rural hospitals costs are 7.1 percent greater than urban costs cancer hospital adjustment Aggregate payment is made to facilities at cost report settlement rather than an adjustment on each claim- this allows facilities to receive an adjustment without negatively impacting co-payments Pass through payment policy Provide hospital with additional payments for high cost drugs, biologicals, and devices -Total payment cannot exceed 2% of total OPPS payments for any given year-specific criteria such as device is different than others and shows substantial clinical improvement What are the 3 components of physician payment? RVU, geographic adjustment, and a conversion factor What are the 3 types of RVUs in RBRVS? Physician
work (WORK) Physician work (WORK) at 51 percent the total RVU weight Practice expense (PE) at 45 percent of the total RVU weight Malpractice (MP) at 4 percent of the total RVU weight List the steps for determining the MPFS amount (review figure 8.3) Determine the procedure code for the service, Other sets by this creatorQuality HIMS12 terms Michelle_CheryPlus Statement of Cash Flows2 terms Michelle_CheryPlus PPE5 terms Michelle_CheryPlus Current Assets13 terms Michelle_CheryPlus Other Quizlet sets39- CMA & BPO23 terms H_Guff Physical science midterm35 terms zx75q9ym8n english57 terms timothymylesraz mock exam 273 terms yelena_beausoleil31 |
Which of the following does not impact the CMG used in the SNF services payment system quizlet?
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