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Question	Answer
In the United States, what is healthcare insurance?	Reduction of a person or group's exposure to risk for unknown healthcare costs by the assumption of that risk by an entity
The physician's office sent a request for payment to Able Insurance Company. The term used in the healthcare industry for this request of payment is a/n_____	Claim
All of the following are discounted fee-for-service healthcare payment methods except:	CRG
A patient saw a neurosurgeon for treatment of a nerve that was severed in an accident. The patient worked for B where the accident occurred. B has WCinsurance. The worker's comp insurance paid the fees of the neurosurgeon, Which entity is the third party?	Worker's compensation insurance
In which type of reimbursement methodology, do healthcare insurance companies reimburse providers after the costs have been incurred?	Retrospective payment
The Physician says theIC is paying for the exacerbation of CHF that the patient had The exacerbation, treatment and resoultion covered 5 weeks. The payment covered all services that the patient had. What method of reimbursment was the practice receiving?	Episode of care
The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan saw 300 patients so he received $4,500 from the health plan. What method is the health plan using to reimburse Dr. Tan?	Capitated rate
In the healthcare industry, what is the term for receiving compensation for healthcare services?	Reimbursement
To which of the following factors is health insurance status most closely linked?	Employment
In which type of reimbursement methodology does the health insurance company have the greatest degree of risk?	Retrospective
The notice from the health insurance plan used the abbreviation "PMPM." How should the insurance analyst interpret this abbreviation?	Per member per month
In which type of healthcare payment method does the healthcare plan pay for each service that a provider renders?	Fee for service
In the health care industry, what is another word for "charge"?	Fee
In the accounting system of the physician's office, the account is categorized as "self pay" How should the insurance analyst interpret this category?	The guarantor will pay the entire bill
What is the term for a predetermined list of charges?	Fee schedule
How could a group of physicians increase the monthly payments the group receives from a healthcare plan that uses capitation?	Renegotiate the contract
In this payment notice (remittance advice), the healthcare plan lists that the payment for the individual lab test is $39. The bill that the pathologist office submitted for the lab test was $45. What does the amount of $39 represent?	allowable fee
Which healthcare payment method does medicare use to reimburse physicians based on the cost of providing services in the terms of effort, overhead and malpractice insurance?	Resource based relative value scale
In which type of health care payment method, does the healthcare plan recompense providers each month with a set amount of money for each individual enrolled in the healthcare plan?	Capitated rate
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 represent?	Global payment
In which type of healthcare payment method, does the healthcare plan recompense providers with a fixed rate for each day a covered member is hospitalized?	Per diem
From the patient's healthcare insurance plan, the rehab 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 insurance plan using?	Case based
All of the following are refined case based payment methods except:	PCGs
The coding system that is used primarily for reporting diagnoses for hospital inpatients is known as	ICD-9-CM
Which of the following coding systems was created for reporting procedures and services performed by physicians in clinical practice?	CPT
Under MS-DRGs, all of the following factors influence a facility's case mix index, EXCEPT for:	The productivity standard for coders
Which of the following is not a reason to perform case mix analysis?	Determine the correct MS-DRG for the encounter
The practice of undercoding can affect a hospital's MS-DRG case mix index in which of the following ways?	Makes it lower than warranted by the actual service/resource intensity of the facilty
Which of the following is the correct format for HCPCS level II codes?	A1234
Which governmental fraud and abuse effort focused on recouping lost funds for the Medicare Program due to inaccurate coding and billing? $188 million were recovered during the first two years of this effort.	Operation Restore Trust
The 6th Scope of Work for Quality Improvement Organizations (QIO) introduced which of the following?	Payment Error Prevention Program
The policies and procedures section of a Coding Compliance Plan should include:	All of the above
MS-DRG relationships comparing with CC (complications/comorbidites) to without CC DRGs for the same clinical condition should be reviewed because:	A and B are both correct
All of the following entities are voluntary healthcare insurance except?	Medicare
Which of the following entities is also known as a "group plan"	Employer based healthcare insurance plan
From figure 1 determine the subscriber	JANE B. WHITE
From figure 1, determine whether the plan covers Gill F. White, Jane's spouse.	No, the card states "employee-only"
What third party payer does figure 1 represent?	Commercial health insurance
According to figure 1, what type of coverage does the third party payer provide Jane B. White?	Individual
From figure 1, determine the insured	STATE
Which of the following characteristics is the greatest advantage of group healthcare insurance?	Greater benefits for lower premiums
Which of the following characteristics is representative of commercial healthcare insurances?	For profit in the private sector
In regards to healthcare insurance, the percentage that the guarantor pays is called the:	Coinsurance
The insurance analyst at the large group practice is responsible for issues related to coordination of benefits. What does he or she do?	Estimates the proportions of the payments from the primary and secondary carriers
Which of the following services has the highest likelihood of being a covered service?	Medically necessary
The guarantor paid $2000 as coinsurance on medical bills. Per the insurance policy, the plan would now pay 100% of remaining bills with no coinsurance being assessed as the guarantor. What type of provision does this clause in the policy represent?	All of the above
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?	policy
All of the following are cost sharing provisions except:	benefit
The child's prescription drug is not on the healthcare plan's formulary. The pharmacist states that the drug's cost is 113.45. Per figure 2, how much should the guarantor expect to pay for the prescription?	$113.45
What does figure 4 represent?	Explanation of benefits
Had the subscriber met the deductible prior to the service?	No, as evidenced by the guarantor's payment of $250
Per figure 4, after the payment of the third party payer, how much will the guarantor have to pay?	$278.60
Per figure 4, how much of the guarantor's payment is coininsurance?	$3.60
_____ ______ Nursing home care	Long term (extended) care
________ salary security for lengthy illness	Disability income protection
______ Accidental amputation	Accidental death and dismemberment
______ Medicare deductibles and coinsurance	Medigap
Which part of the Medicare program was created under the Medicare Modernization Act of 2003 (MMA)?	Part D
This program, formerly CHAMPUS (civilian health and medical program - uniformed services) provides coverage for the dependents of active members of the armed forces	TRICARE
Which government sponsored program replaced the Aid to Families with Dependent Children (AFDC) program in 1996.	Temporary Assistance for Needy Families Program (TANF)
Which of the following is NOT a function of the Indian Health Service (IHS)	Provides only inpatient healthcare services
The civilian health and medical program of the department of veterans affairs (CHAMPVA) is available for:	B and C ( Veterans of the Armed Forces, Children of a veteran meeting specific criteria)
Which of the following is/are true of SCHIP?	A and C (Is a federal/state program, varies from state to state)
The medicare program is divided into _____ parts	4
Medicare part C is a ________ option known as Medicare Advantage	managed care
All of the following are true of state Medicaid programs EXCEPT:	Services offered to beneficiaries are the same in each state
Which TRICARE program offers services to active duty family families (ADFMs) with no enrollment, deductible, or copayment fees for covered services?	TRICARE Prime
In which type of HMO are the physicians employees?	Staff model
Today's managed care traces its origins to all of the following arrangements except:	1800, congress awarding pensions for US naval personnel on the basis of death or disability during active service
Why did Congress pass the Health Maintenance Organization Act of 1973?	To encourage the delivery of affordable quality healthcare
All of the following are characteristics of managed care organizations except:	Freedom of choice and autonomous decision making
Access to mental or behavioral health or medical specialists is through referral. What is the term for the individual who makes the referral?	All of the following (primary care provider, gatekeeper, primary care physician
All of the following are characteristics of disease management except:	Focus on single specialist for acute disease
What is the term for an explicit statement that directs clinical decision making?	Evidence based practice guidelines
All of the following are tools managed care organizations use to promote quality care in their healthcare plans except:	Incentive to meet fiscal targets
All of the following are purposes of the surveys that managed care organizations send their patient/members except:	Reasons for referrals to specialists
What is the term that means evaluating, for a healthcare service, the appropriateness of its setting and its level of service?	Utilization review
Which of the following services is most likely to be considered medically necessary?	Standard of care for health condition
All of the following sets represent criteria for medical necessity and utilization review except:	Federal register index and ratings
All of the following services are typically reviewed for medical necessity and utilization except:	Well baby check
Gatekeepers determine the appropriateness of all of the following components except:	Rate of capitation or reimbursement
The patient belonged to a managed care plan. Prior approval for the surgery was received. What number should the insurance analyst record?	Precertification
The patient belonged to a managed care plan. The patient had an elective surgery had not been obtained. What should the patient expect?	Denial of reimbursement for the surgery
For which one of the following healthcare services is the managed care plan least likely to require a second opinion?	Treatment protocols that have low risk
For what type of care should the physician practice manager expect to work with a case manager?	Worker's compensation
What is the term for contracts that separate out certain types of healthcare services to decrease MCO's risk?	Carve out
All of the following are elements of prescription management except:	Links to electronic banking
All of the following attributes characterize episode of care reimbursement except:	Retrospective fee for service
The primary care physician did not meet the MCO's target for counseling cardiac patients about smoking cessation. The primary care provider could expect any of the following results except	bonus
A patient, who was a medicaid recipient asked about the types of fiancial incentives that the MCO used. What should the MCO's administrator do?	Release summaries of the financial incentitves
The patient belongs to a managed care plan. The patient wants to make an appointment with an out of network specialist. The plan has approved the appointment as "out of plan". What should the patient expect:	The patient's out of pocket costs will be increased.
Of the following types of MCOs which ones has the strictest procedures for control of cost?	Staff model
What is meant by the phrase "point of service" in "point of service insurance plan"?	Members choose the reimbursement model (HMO, PPO, fee for service) when they need healthcare services rather than during the open enrollment period.
What is the term for an MCO that serves Medicare beneficiaries?	Medicare advantage
Integrated delivery systems use varying degrees of integration. Which degree of integration is least binding?	Affiliation
In the group practice, the physicians have maintained their separate practices and offices. The individual practices share administrative systems to form a group practice. Which form of integrated delivery system does this arrangement represent?	Clinic without walls
Which of the following features is a benefit of consumer directed healthcare plans?	Patient's awareness of and responsibility for healthcare costs
Which of the following points is a guideline for the acute hospital payment system?	Incentive for cost control because hospitals retain profits or suffer losses based on differences between payment rate and actual costs
What is the average of the sum of the relative weights of all patients treated during a specified time period?	Case mix index
The MS-DRG payment includes reimbursement for all the following inpatient services except:	Progress notes
Select the highest level of the IPPS hierarchy:	Major diagnostic category
What is the general term for software that assigns inpatient diagnosis related groups?	Grouper
What is Medicare's term for a facility with a high percentage of low income patients?	Disproportionate share hospital
What condition does CMS require be met for a facility to receive the indirect medical education adjustment?	Medical residents in an approved graduate medical education program
New medical technologies are often very expensive. What is the CMS's position on the use of technologies to treat Medicare beneficiaries?	CMS encourages the use of new technologies through a regulatory process that formally identifies a status of "new technology" and thereby, allows a payment for the full DRG plus 50% of the new technology's cost.
What is the name of the entity that pays Medicare Part A claims?	Medicare Administrative Contractor
In the MS-DRGs, for what is the case mix index a proxy?	Consumption of resources
In the IPPS, what is the term for each hospital's unique standardized amount based on its costs per Medicare discharge?	Base payment rate
What is the basis of the labor related share?	Facilities costs related to payrolls, benefits, and professional fees
A Medicare patient was discharged from one acute IPPS and admitted to another acute IPPS hospital on the same day. How will the two acute IPPS hospitals be reimbursed?	The first hospital receives a per-diem payment derived from the potential MS-DRG and the second hospital receives the full MS-DRG
For purposes of Medicare reimbursement, which of the following situations represents a discharge from the the first acute IPPS hospital?	The patient is discharged from one acute IPPS hospital and is admitted to a second acute IPPS hospital on the 3rd day.
Which is the correct formula for wage index adjustment?	(payment ratelabor portion WI) + (payment rate * labor portion)
Which reimbursement scheme is used in the Inpatient Psychiatric Facility Prospective Payment System?	Per diem rate
Which of the following is NOT a provision of the IPPS?	Length of stay outlier
Under the IPF PPS which states are included in the cost of living adjustment (COLA)?	Alaska and Hawaii
Which of the following is NOT a patient level adjustment used in the IPF PPS?	Full service emergency department
Medicare inpatient reimbursement levels are based on ______?	MS-DRG calculated for the encounter
Which congressional act called for the creation of a PPS for the psychiatric inpatient setting?	Balanced Budget Act Refinement Act of 1999
Its the year of 2000. The Fed Gov. is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government reduce?	Conversion factor
What is the term for an index based on relative differences in the cost of a market basket of goods across areas?	GPCI
All of the following elements are used to calculate a Medicare payment under the RBRVS EXCEPT:	Extent of the physical exam
Which of the following statements characterizes the RBRVS payment system?	RBRVS payment system reflects the skill and resources required for each procedure
Which researcher is associated with the RBRVS payment system?	Hsaio
Which university is associated with the development of the RBRVS payment system?	Harvard
Which of the following sites is considered a facility in the RBRVS payment system?	Ambulance
Which element of the RVU accounts for the cost of the medical practice, such as office rent, wages of nonphysician personnel and supplies and equiptment?	Practice expenses
All of the following items are packaged under the Medicare Hospital Outpatient Prospective Payment System (HOPPS) except for	Medical visits
Under the HOPPS, outpatient services that are similar both clinically and in use of resources are assigned to separate groups called ______?	APCs
Which of the following statements is true about APCs?	APCs are based on the CPT or HCPCS code(s) reported
In the APC system, an outlier payment is paid when which of the following occurs?	The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount
Which of the following status indicators indicates that the APC payment is reduced when multiple procedures with this status are reported together?	T- surgical service
What is the maximum number of APCs that may be assigned per encounter?	unlimited
The prospective payment system used by hospitals for the majority of services provided to Medicare hospital outpatients is called _______ and became effective on ______.	Ambulatory Payment Classifications, Jan 1, 2000
This PPS has been adopted for use by many third party payers (that is, Medicaid) for reimbursement of outpatient visits. It is NOT the methodology used by Medicare	APGs (ambulatory patient groups)
These are financial protections were created to ensure that certain types of facilities (that is, cancer hospitals and small rural hospitals) recoup losses incurred due to payment differences between the HOPPS and pre HOPPS (reasonable cost) payments	hold harmless
The HOPPS encompasses a variety of PPSs, All of the following are HOPPS systems EXCEPT:	percent of billed charges
Several acts influenced the creation and establishment of the current HOPPS (APCs) Which of the following acts did not influence the creation and establishment of HOPPS?	Omnibus consolidated and Emergency Supplemental Appropriations Act of 1999
Which Medicare fee schedule uses a 5 year transition period to switch from a reasonable cost/charge based system to a PPS?	Ambulance
What term is used to indicate that an ambulance service entity is associated with a medical facility?	Provider
Which act of congress added a new section to the SSA calling for the creation of a PPS for ambulance services?	Balanced Budget Act of 1997
The Ambulance Fee Schedule was implemented on _______.	April 1, 2002
Under the Ambulance Fee Schedule the_______ is used to determine the level of service for ground transport.	EMS provider skill sets used during the transportation.
Which of the following is NOT an adjustment provided under the Ambulance Fee Schedule?	Urban area service adjustment
When a patient is pronounced dead prior to an ambulance being called, which of the following payment provisions is followed under the Ambulance Fee Schedule?	no payment is made to the ambulance supplier/provider
The Omnibus Budget Reconciliation Act of 1980 amended the SSA to specify which procedures would be covered under the prospective payment system for Ambulatory Surgical Centers, This PPS is officially named:	The ASC list of covered procedures
Which is the correct formula for wage index adjusting a payment?	(payment ratelabor portion WI) + (payment ratenonlabor portion) (payment rate WI)
Under the ASC List multiple procedures performed during the same surgical session are reimbursed at which of the following rate?	The procedure in the highest level group receives full payment and the remaining receive half (50%) payment
The medicare moderization act of 2003 mandated the creation of a new PPS for ASC services_________	between 2006 and 2008
The medicare moderization act of 2003 mandated the creation of a new PPS for ASC services because ________	There is disparity between ambulatory surgical center and hospital outpatient facility payments for the same service
Medicare-certified ASCs must accept assignment, meaning	an ASC must accept medicare payment as payment in full
Under the SNF, PPS which of the following healthcare services is excluded from the consolidated payment?	Radiation therapy
Which classification system is used to case mix adjust the SNF payment rate?	Resource utilization groups
In the SNF PPS, which data set determines a resident's classification into a resource utilization group?	Minimum data set
The therapist in the skilled nursing facility is treating multiple patients who are each performing different therapies. How does tthe CMS classify this mode of delivery?	Concurrent
In the PAC payment systems, which tool does CMS use to adjust its payment rates to account for geographic variations in costs?	Market basket
In which of the PAC payment systems, is the unit of payment the 60 day episode of care?	Home health agency
CMS analysts divide SNF admissions into upper and lower categories. For which of the following categories requires is the resident's admission justified on an individual basis?	Special care
Generally, what is the average length of stay of long term care hospitals?	>25
Patients with all of the following conditions are appropriate for LTCH's except:	acute myocardial infarction
In terms of their composition, how do groups of the MS-LTC_DRGs compare to the groups of the acute care MS-DRGs?	exactly the same
In terms of grouping and reimbursement, how are the MS-LTC-DRGs and acute care MS-DRGs similar?	Based on principal diagnosis
In the LTCH PPS, what is the standard federal rate?	constant that converts the MS-LTC-DRG weight into a payment
According to the CMS, what is one purposes of the IRF PPS?	To promote equity for beneficiaries, facilities, and taxpayers
To meet the definition of an IRF, facilities must have an inpatient population with at least a specified percentage of patients with certain conditions. Which of the following conditions is counted in the defintion?	Brain injury
All of the following elements are part of the IRF PPS except:	major diagnostic category
All of the following types of diagnoses are used in the IRF PPS except:	Principal
In the IRF, PPS what is the tool for data collection that drives payment?	Patient assessment instrument
What data set provides the underpinning of the HHPPS?	OASIS
All of the following services are consolidated into a single payment under the HHPPS EXCEPT:	Durable medical equipment
All of the following domains are part of the HHPPS case mix index EXCEPT:	Medical malpractice
How many HHRGs are there?	153
For what variations in resource consumption does the HHPPS account?	Number of therapy visits by a therapist
Which of the following elements is directly adjusted by the local wage index?	Labor portion
In which of the PAC payment systems, is the adjusted rate multipied by the patient's number of Medicare days to determine the reimbursement amount?	Skilled nursing faciltiy
What is the term used in a Rehab Facility to mean a "patient's ability to perform activities of daily living"?	Functional status
What targets should be the focus of pay per performance or value based purchasing systems?	Targets for which valid and reliable performance measures are available
Which of the following situations would be included in a penalty based model of pay per performance?	Compensation withheld for lack of improvement
Which of the following entities sponsor value based purchasing or pay for performance systems?	Centers for Medicare and medicaid services, Employers health plans all of the above
How do organizations control costs indirectly?	reduce errors
Why are incremental implementations of pay for performance systems perferable to full scale implementations?	sponsors can evaluate policies and procedures
In value based purchasing and pay for performance systems, characteristics of adopted performance measures should include all of the following EXCEPT:	Authoritarian
Which of the following incentives is non-fiancial?	Public report cards
In order for p4p abd VBP systems to function properly, the system must be able to identify the clinican who provided the care and is responsible for the care's quality. In P4P and VBP, this process is known as	Attribution
The tax relief and health care act of 2006 (MIEA-TEHCA) expanded CMS quality initatives to which two setting?	Hospital outpatient departments and ambulatory surgical centers
Which condition is not included on the hospital acquired conditions provision list for FY 2009?	Staphylococcus infections

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