Reimbursement Test 2 Part 2

rad2329's version from 2016-10-11 20:10

Section 1

Question Answer
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) legislation ? Extensive changes to Medicare, Mandated the implementation of a PPS for inpatient facilities,Allowed some facilities to continue cost-based payment (TEFRA hospitals).
CCRCost to Charge Ratio
IPPSInpatient prospective payment system
Legislation adopted classification system from New Jersey’s demonstration project ?Diagnosis Related Groups (DRGs), Implemented October 1, 1983 (This was the pilot for the DRGs).
Medicare Reimbursement History - Retrospective is ____ ?Cost-based, Payment is not known at start of treatment.
Medicare Reimbursement History - Prospective is ____ ?Based on Average Cost, Payment is established at start of treatment.
DRGDiagnosis Related Group
Define case mix?A description of a patient population based on any number of specific characteristics, including age, gender, type of insurance, diagnosis, risk factors, treatment received, and resources used.
CMICase-mix index
A coder finds the highest what?MSDRG – The DRG’s without CC’s to increase the DRG.
MCCMajor Complication or Comorbidity
MDCMajor diagnostic category
Define Principal diagnosis?established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Section 2

Question Answer
Acute-care facility Excludes (These have there own payment systems) ?Psychiatric unit, Long-term care unit, Rehabilitation unit.
Inpatient prospective payment system (IPPS) Fiscal Year for the Federal Government is ?Oct 1 – Sept 30 updated yearly
Regarding Medicare Reimbursement History, - Prior to prospective paymentConvert total charges to cost using department-specific cost-to-charge ratios (CCRs).
Prior to prospective payment, Cost-based payment entailed ?Reasonable cost, Cost of services, Per-diem cost
Cost to Charge Ration(CCR) is taken from ?Cost report statistics for each facility
What can happen when healthcare costs increase?As costs increase so does the facility payment – leaving the payment amount unpredictable for the payer (Medicare)
Why is reimbursement not consistent among facilities?Because each facility has a different cost for providing services.
What was the motivation for development of Diagnosis Related Groups (DRGs)?Establish an effective framework for monitoring Quality of care and Utilization of services.
Diagnosis Related Groups (DRGs) were the first system to allow the measurement of a hospital’s case-mix (CM) complexity and is a direct measure of?The resource consumption and therefore the cost of providing care
Patient characteristics used in the definition of Diagnosis Related Groups (DRGs) should be limited to ?Information routinely collected in hospital abstract systems.
Diagnosis Related Group (DRG) costs are reimbursed at ?80 percent of costs.
For billing purposes how many total procedures (px) can be submitted to Medicare for billing purposes? The top 25
Physician-Hospital Organizations (PHOs) make it possible for the managed care market to ___ ?View the hospital(s) and physicians as a single entity for the purpose of establishing a contract for services

Section 3

Question Answer
Give 3 reasons why Medicare moved to Prospective Payment?Incentive for hospitals to operate more efficiently, Prior three years Medicare payments had increased 19 percent, or three times the overall rate of inflation, The deductible for beneficiaries continued to increase.
The Diagnostic Related Group (DRG) system was not originally created to be ?A reimbursement system
What are Diagnosis Related Groups (DRGs)?A system that takes into consideration the role that a hospitals’ case mix plays in influencing costs.
Regarding the concept of Prospective Payment Demonstration Projects in 1972 were based on four guiding principles?Establish payment rates in advance (prospective) and apply as “fixed”, Rates not automatically determined by the hospital’s past or current actual cost, Payment is payment in full, Hospital retains profit or loss, thus creating an incentive for cost control
Give 4 reasons why Medicare moved to Prospective Payment?Healthcare costs were on the rise—draining the Medicare Trust Fund, No money available for Medicare to fund other programs, Hospital payment greatly varied from hospital to hospital for the same services, Eliminate burdensome reporting requirements.
Define case mix?Set of categories of patients (type and volume) treated by a healthcare organization and representing the complexity of the organization’s caseload.
Define case mix index (CMI)?The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system; calculated by dividing the sum of the weights of diagnosis-related groups for patients discharged during a given period divided by the total number of patients discharged.
A DRG system takes into consideration the role that a hospitals’ case mix plays in influencing costs how?It relates the type of patients a hospital treats (case mix) to the costs incurred, Groups like patients with like resource consumption and LOS patterns together, Shows the clinical complexity and consumption of hospital resources
Patients are grouped into Diagnosis Related Groups (DRGs) based on ?Principal diagnosis, Comorbidity, Complication, Principal procedure, Secondary procedure, Sex, Age, Discharge Status.
Why does discharge status play a factor in payment and some Diagnosis Related Groups (DRGs)?Need to know where the patient went after discharge.
Why is one DRG assigned per encounterThe costs for all services are included in the payment for one DRG, Facility accepts profit or loss, Drives facilities to practice cost management.

Section 4

Question Answer
Each DRG group has a set payment rate that is based on ?Historical charge and payment data.
Why did DRGs move to a severity adjusted system?MedPAC recommended that CMS refine the current DRGs to more fully capture differences in severity of illness among patients,To not create an incentive for hospitals to avoid treating high-cost cases due to inequity in payments for complex cases, Reimburse cases with a more complex mix of services at a higher rate.
In order to be practical and meaningful, the DRG system needed to meet the following four criteria?Patient characteristics used in the definition of DRGs should be limited to information routinely collected in hospital abstract systems. There should be a manageable number of DRGs, which encompass all patients seen on an inpatient basis. Each DRG should contain patients with a similar pattern of resource intensity. Each DRG should contain patients who are similar from a clinical perspective.
DRG assignment is primarily based on?Diagnosis and/or procedure performed.
Define a Medicare severity Complication?A condition arising during the hospital stay that prolongs the Length of stay (LOS) by at least one day in approximately 75 percent of the cases.
Define a Medicare severity Comorbidity?A pre-existing condition which because of its presence with the principal diagnosis will increase the LOS by at least one day in 75 percent of the cases.
A complex case mix in DRG terms does not imply ?The hospital treats patients having a greater severity of illness, higher risk of mortality, greater treatment difficulty, poorer prognosis, or greater need for intervention.
A hospital with a complex Case Mix (CM) means ?The hospital patients are consuming more resources, and therefore the cost of care is higher.
Required information for Patient health information (PHI) data needed to group MS-DRGs ?One principal diagnosis (dx) and up to 24 additional dx (25 total), One principal procedure (px) and up to 24 additional px (25 total), Age, Sex, D/C status.
Regarding the Relative weight, the higher the weight the ?Higher the DRG
What drives the assignment of the 15 MS-DRGs?The resource intensity of the procedure.
List the Steps of the MS-DRG Assignment ?Pre-MDC assignment, MDC determination, Medical/Surgical status determination,

Section 5

Question Answer
MDC Assignment ?Major diagnostic category (25 options)
MSDRG Assignment Step 1: Pre-MDC assignment ?15 MS-DRGs for which the MDC of the principal diagnosis is not taken into consideration for MS-DRG assignment, The cases are directly assigned based upon procedure codes only.
MSDRG Assignment Step 2: MDC Determination ?What is the MDC of the principal diagnosis.
MSDRG Assignment Step 3: Medical/Surgical status determination ?Was an operating room (OR) procedure performed. Yes: surgical status,No: medical status.
MSDRG Assignment Step 4: Refinement ?Various questions are used to isolate the correct MS-DRG assignment.
This is a generic term for prepaid health plans that integrate the financial and delivery aspects of healthcare services?Managed care
HMOs are ?Prepaid voluntary health plans that provide healthcare services in return for a monthly premium (Page 256)
APA is _____ a type of HMONot
What is general term for software that assigns inpatient diagnoses related groups (DRG)?Grouper
What is the average of the sum of relative weights of all patients treated during a specified time period?Case Mix Index (CMI)
What is the rate year (RY) for IPPS (time period for IPPS - when does it start and when does it end) FYI think fiscal year?Oct 1 - Sept 30

Section 6

Question Answer
Define Integrated Provider Organizations:Managed and coordinated the delivery of healthcare services performed by a number of healthcare professionals and facilities (physicians are salaried employees)
The MDC of the principal diagnosis is used for ?Assignment
The Refinement MS-DRG process allows ?The MS-DRG system to group together like patient from the clinical perspective with like resource consumption.
In which government publication are the details about the various PPS related information commented on and finalized?Federal Register
What is the name of the severity-adjusted DRG system adopted in FY 2008?MS-DRG
What are Integrated Provider Organizations also known as?Delivery systems, horizontally integrated systems, health delivery networks, accountable health plans, integrated service networks (ISNs), Vertically integrated plans (VIPs), and Vertically integrated systems.
Define Management Service organizations?Provides practice management (administrative and support) services to individual physicians’ practices.
Medical Foundations owns what?business resources and makes them available to the participating physicians. (Clinical assets such as medical equipment, supplies, and treatment facilities. Business assets such as billing and administrative support systems.)
Define Medical Foundations?Nonprofit organizations that enter into contracts with physicians to mange the physician’s practices
Define Physician-Hospital Organizations (PHOs)?They provide healthcare services through a contractual arrangement between physicians and hopsital(s). Previously known as medical staff-hospital organizations.