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Principles of Healthcare Reimbursement


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ACO (Accountable Care Organization)
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primary care-led physician and hospital organizations that voluntarily form networks

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ACO (Accountable Care Organization)
Primary care-led physician and hospital organizations that voluntarily form networks
Adjudication is the process where
The payer verifies that their billing requirements have been met, and then they determine which services are eligible for reimbursement
Per capita means
Per head or per person
PMPM stands for
Per member per month
Prospective reimbursement methodologies include
Capitation, case rate, global payment, and bundled payment
Prospective reimbursement is a payment method where
Providers receive a predetermined amount for all the services they provide during a timeframe
The unit of payment in prospective reimbursement is
The encounter, established period of time, or covered life
Case-rate methodology is a payment method where
The 3rd party payer reimburses the provider one amount for the entire visit or encounter
Case-rate payment rates are based on
Historical data about typical costs for patients within a group
The global payment method is a payment method where
A 3rd-party payer makes one combined payment to cover services of multiple providers who are treating a single episode-of-care.
The global payment method is typically used for
Physician services and outpatient care
In a bundled payment methodology, a predetermined payment amount is provided for
All services required for a single predefined episode-of-care
2 criticisms of prospective payment are
1) this method creates incentive to use less expensive diagnostic tests, therapeutic procedures, etc 2) creates incentive to delay or deny procedures and treatments that are costly
Examples of retrospective payment methodologies include
Fee schedule, percent of billed charges, and per diem
A fee schedule is based on a
Pre-determined list of fees that a 3rd party payer will pay for certain healthcare services
Fee schedule is considered a retrospective reimbursement methodology because
Which services and the volume of services will not be known until after care has been provided
Criticisms of retrospective reimbursement methodologies include
1) few incentives to reduce costs 2) less incentive to order less expensive services
Insurance is a system of
Reducing a person's exposure to risk of loss by having another party assume the risk
A risk pool is
A group of insureds who have a similar risk of loss
The premium is
The amount paid by a policyholder for a certain time period of coverage by an insurance company
3 national models of healthcare delivery are
1) social insurance 2) national health insurance and 3) private health insurance
The social insurance model is also known as
The Bismarck model (originated in Germany)
The national health service model is also known as
The Beveridge model (originated in UK)
The Beveridge model is characterized as
A government-run model that is a single-payer health system
3 characteristics that are key to understanding the U.S. healthcare sector are
1) the size 2) the complexity and 3) the intricate payment methods and rules
2 major trends of the U.S. healthcare sector are
1) healthcare spending is constantly increasing and 2) efforts to reform the healthcare system
3 core problems in the US health system are
1) excessive cost 2) inequitable or unsafe care 3) lack of access
This law designated the code sets for healthcare services reporting to public and private insurers
The Health Insurance Portability and Accountability Act (HIPAA) of 1996
ICD-10-CM was developed by
The National Center for Health Statistics (NCHS)
Uses of ICD-10-CM include
1) collect administrative data on medical processes and outcomes 2) for reimbursement systems and 3) integrating into EHRs
ICD-10-CM and ICD-10-PCS serve as
The communication vehicle between providers and insurers
CDMs stand for
Charge description masters
CPT is used by
1) physicians to report services they performed (inpatient and outpatient) and 2) facilities for outpatient services and procedures
The CPT was developed and is maintained by
AMA (American Medical Association)
Category III codes in CPT are
Temporary codes that represent new and emerging technologies
HCPCS level II is used to report codes for
Supplies, services, and procedures not represented in CPT
The purpose of the CMS hierarchical condition categories (HCC) model is to
Provide fair and accurate payments while rewarding efficiency and high-quality care for Medicare's chronically ill patients
This act allows for fines up to $10,000 per violation for Medicare fraud or abuse.
The Medicare and Medicaid Patient and Program Protection Act of 1987
OIG stands for
Office of Inspector General
Operation Restore Trust was released in 1995 to
Target Medicare and Medicaid fraud and abuse among healthcare providers and was a major push for accurate coding and billing
Medicare Summary Notices (MSNs) were formerly known as this
Explanations of Medicare Benefits (EOMBs)
IPERA stands for
Improper Payments Elimination and Recovery Act (2013)
This act strengthened efforts to identify, prevent and recover improper payments
IPERIA (Improper Payments Elimination and Recovery Improvement Act)
RACs stands for
Recovery audit contractors
RACs are reimbursed via
A contingency fee based on the amount of improper payments
A vulnerability is a
Type of claim that is vulnerable to improper payments, which is a financial risk to the Medicare program
RVC stands for
Recovery audit validation contractor
CMS uses this type of contractor to ensure accuracy of RACs
RVCs (recovery audit validation contractors)
MACs and QICs are
Parties who receive and decide on appeals about claims