A type of reimbursement used by CMS that bases Medicare payments on a predetermined, fixed amt (e.g. DRG's for inpatient hospital service) is called?
What is Prospective payment system.
100
When an insurance carrier makes a payment to the patient/insured OR provider for a covered expense, it is referred to as?
What is reimbursement.
100
A payment system whereby the healthcare provider is paid a fee for each service or supply provided, and fees are billed at a rate established by the provider is called?
What is Fee-for-service.
100
Which organization has been given primary authority for puttin PPS into practice?
What is CMS - Centers for Medicare/Medicaid Services.
200
The amt of payment in the PPS (based on the classification of that system, Medicare) is determined by the assigned?
What is DRG - diagnosis-related group.
200
What is the method of payment for healthcare services whereby the provider is paid a fixed amt for each patient regardless of the actual number or nature of service provided?
What is Capitation.
200
Medicare's PS for reimbursing hospitals for providing INPATIENT care to beneficiaries is referred to as?
What is IPPS - Inpatient prospective payment system
200
PRO
What is Peer review organization; Organization (composed of physicians and other healthcare professionals) that the federal government pays to evaluate services and monitor the quailty of patient care provided by other practitioners.
200
What ACT limits Medicare reimbursement that is applied to stays in long-term acute care hospitals?
What is TEFRA - Tax Equity & Fiscal Responsibility Act, enacted by Congress in 1982.
300
When determining the applicable DRG classification, the key piece of information is the Patient's?
What is Principal Diagnosis.
300
What is the term for the presence of more than one disease or health condition in an indvidual at a given time?
What is Comorbidity,
300
Medicare's inpatient hospital classification system used to pay a hospital or other provider for services, categorizing illnesses/conditions by DX and treatment?
What is DRG - Diagnosis-related group
300
APCs
What is Ambulatory Payment Classifications - service classification system that was designed to explain the amount and type of resources used in an outpatient encounter.
300
NonPARs not accepting assignement can charge beneficiaries no more then what precent of the Medicare allowed fee schedule?
What is 115% .
400
Resource Utilization Groups (RUGs) are used to calcualte payments according to severity and level of care in what type of facilities?
What is Skilled Nursing Facilities.
400
LTCH that are significantly shorter than the average length of stay for a long-term care DRG is referred to as what?
What is Short-stay outliner.
400
IN the HHPPS - Home Health Prospective payment system, determination of payment is dependent on ?
What is OASIS - Outcome & Assessment information set.
400
GPCI
What is Geographic Practice Cost Index - Factor used by Medicare to adjust relative value unit weights for various localities in the United States that have differing costs for providing healthcare.
400
Name the 4 reimbursement methods.
What is Fee-for-service, Discounted fee-for-service, Prospective Payment Systems, & Capitation.
500
Under Medicare's PPS, long-term care hospitals generally treat patients who require hospital-level care for an average of how many days?
What is 25 days.
500
What is the term for the agreement between the provider and a third-party payer whereby the provider agrees to accept the payer's allowed fee as payment in full for a particular service or procedure?
What is a Contractual write-off.
500
Medicare prospective payment system a acute inpatient hospital care was mandated by who?
What is Social Security Amendments of 1983.
500
RBRVS
What is Resource-Based Relative Value Scale - Omnibus Budegt Reconciliation Act of 1989 legislated a system to replace the UCR method of generating professional fees.