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CHFP Module 1 Certification Test
Question and Answer
Is a pre-determined amount that the patient pays before the insurer begins to pay for services - Answer -deductible a percentage of the insurance payment amount that is paid by the patient, along with the amount paid by the insurer. - Answer - coinsurance a flat amount that the patient pays at each time of service - Answer -copayment payment also includes amounts for services that are not included in the patient's benefit design and amounts for services balance billed by out-of-network providers. Payments typically does not include premium sharing by the patient. - Answer -Out-of-pocket payment The amount payable out of pocket for healthcare services, which may includes deductibles, copayments, coinsurance, amounts payable by the patient for services that are not included in the patient's benefit design, and amounts "balance billed" by out-of- network providers. Health insurance premiums constitute a separate category of healthcare costs for patients, independent of healthcare utilization. - Answer -Cost (to the patient) The expense (direct and indirect) incurred to deliver healthcare services to patients. - Answer -Costs (to the provider) The amount payable to the provider (or reimbursable to the patient) for services rendered. - Answer -Cost (to the health plan/insurer)
The expense related to provided health benefits (premiums or claims paid) - Answer -Cost (to the employer) The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid. - Answer -Charge The total amount a provider expects to be paid by health plans/payers and patients for healthcare services. - Answer -Price An organization that negotiates or sets rates for provider services, collects revenue through premium payments or tax dollars, processes provider claims for service, and pays provider claims using collected premium or tax revenues. - Answer -Health Plan/Payer An entity, organization, or individual that furnishes a healthcare service. - Answer -Provider Occurs when a healthcare provider bills a patient for charges (other than copayments, coinsurance or any amounts that may remain on the patient's annual deductible) that exceed the health plan's payment for a covered service. In-network providers are contractually prohibited from balance billing health plan members, but balance billing by out-of-network providers is common. - Answer -Balance Billing In healthcare, readily available information on the price of healthcare services that, together with other information, helps define the value of those services and enables patients and other care purchasers to identify, compare and choose providers that offer the desired level of value - Answer -Price Transparency The quality of a healthcare service in relation to the total price paid for the service by care purchasers. - Answer -Value
-Rare not all insurers participate in provider networks that give them access to contracted payment rates. Some auto insurers, liability insurers or companies providing travel insurance to visitors from abroad still pay a provider's full charges.
- Percent-of-Charge Contracts -In markets with little competition, percent-of-charge contracts are still common. The higher the price, the higher the percent-of- charge payment, unless the contract limits a provider's annual price increases.
- Outlier Provisions -Some insurance contacts contain an outlier provision that entitles providers to an additional payment (a lump-sum payment or a percentage of actual charges above a threshold) for particularly sick and high-cost patients. What is the use and benefits of Cost Based Payments? - Answer -The only use of this method today is in a limited set of small, rural healthcare facilities known as critical access hospitals. This mechanism has rarely been used for physicians. Cost-based payment calls for the insurer to pay the healthcare provider based on the costs of providing services, with a nominal allowance for margin. What is the Medicare program began with a payment mechanism to healthcare facilities that has since been nearly eliminated from the healthcare industry — - Answer -Cost based Payment Which of the following would benefit the most from a cost-based payment method? - Answer -The healthcare provider That's right! Let's understand how. The payment mechanism is advantageous for healthcare providers, as there is a higher likelihood that all costs will be paid, and there is no incentive to be efficient in providing care, since costs will be reimbursed by the insurer. The rapid escalation of
healthcare costs in the U.S. after the start of cost-based payment in Medicare and Medicaid programs led to the implementation of the Prospective Payment System (PPS) of paying acute care healthcare providers for inpatient services in 1983 and outpatient services in 2000. Since then, CMS has introduced prospective payment systems for most other types of institutional healthcare providers Cost-Based payment decreased need for providers to be efficient. Mountainside Health Plan is evaluating its payment of hospitals in its current service area. It is looking to reduce its costs per patient and stabilize its overall payments to hospitals. Which of the following payment methods would be least effective for the health plan to meet these objectives? - Answer -Cost-based payment You selected the correct Answer. Cost-based payment is the least predictable model for a health plan and has the greatest risk of increased cost because it is dependent on the hospital's ability to manage operating costs. The table below shows the methods ranked from most predictable to least predictable. What are the 5 main types of prospective payments used in today's healthcare market? - Answer -1. DRG healthcare provider
- Per Procedure
- Case rate - healthcare provider or physician
- Per diem - healthcare provider
- Bundled payment - healthcare provider, physicians and post- acute providers A payment based on the patient's diagnosis is known as a - Answer -(DRG) Diagnosis Related Group
What payment approach is the physician payment per procedure or service, varies based on the amount of resources (usually time and effort) needed by the physician. - Answer -Resource Based Relative Value Scale (RBRVS) __________ at 100% of the per-procedure fee - Answer -Primary procedure _________ at 50% of the normal per-procedure fee - Answer - Secondary procedure _________ 25% of the normal per-procedure fee - Answer -Third and Subsequent procedure What are the common discounting approches? - Answer - primary , secondary, and third/subsequent procedures Affiliated Health Plan is negotiating a new contract with a local ambulatory surgery center. Previously, Affiliated paid that surgery center on a discount-off-of-billed charges basis and is trying to change to a per-procedure method of payment. Which of the following mechanisms must Affiliated have in place in order to control its risk of increased costs? - Answer -A utilization management program Because a per-procedure method creates an incentive for providers to bill for more procedures, the health plan must monitor utilization and make sure that only medically necessary services are provided. Predetermined amount paid to a healthcare provider for a specified service or range of services. - Answer -Case rate What is the difference between case rate and DRG - Answer -The difference between case rate and DRG is that the case rate
encompasses a group of similar procedures while the DRG can be specific to a unique diagnosis and may or may not include a procedure. Where is a common area where case rates would be used? - Answer -Cardiac surgery which is used primarily for payment to long-term care facilities. - Answer -Per diem (or per day) payment system What health plan reimburses a facility a fixed amount per day for care to a patient - Answer -per diem payment system Cons of per diem system - Answer -The rate may be higher or lower depending on the type of service the patient receives; that is, per diem or per-day payment for an intensive care unit (ICU) may be higher than the payment for a day in a medical/surgical unit. This differing level of payment recognizes that a provider will spend more to care for a patient in ICU than for the more routine level of care provided in a medical/surgical unit. What are benefits of Per Diem system - Answer -the per diem payment is administratively easy for the health plan and provides a predictable payment rate that is useful in setting competitive premium rates. However, the facility has a strong incentive to keep a patient longer, since an additional day of service increases payments. This requires the health plan to monitor patient length of stay to verify that the patient stay is only for the number of days that are medically necessary. This process is referred to as concurrent review. involves staff from the facility working with the health plan to review the medical justification and obtaining a certification of necessity for the patient's continued stay. This process can be
_________ at 50% of the normal per-procedure fee - Answer - Secondary procedure _________ at 50% of the normal per-procedure fee - Answer - Secondary procedure The average level of severity of conditions of patients in a healthcare provider during a specified period is known as - Answer -case mix index are examples of risk-based contracts. - Answer -medicare Shared Savings Accountable Care Organizations (MSSP ACOs) established by the Affordable Care Act and the Quality Payment Program (QPP) established by the Medicare and CHIP Reauthorization Act ______ _________ contracts generally overlay a conventional payment methodology (such as fee-for-service, per diem, per case or episodic) with a retrospective settlement mechanism that shares savings (known as upside risk) or losses (downside risk) from the negotiated target. Risk-based contracts may also include provisions that reward providers for achieving certain non-cost related metrics such as quality goals or penalize them for not meeting (or reporting) them. - Answer -risk based _________ the payer (government or commercial) and the provider (or group of providers) share financially in both the risks and the rewards of providing healthcare services at a negotiated rate, giving all parties a financial stake in the contract's performance. (definition) - Answer -risk based contract From the perspective of the medical group, charge-based payment poses the least financial risk since the group has control over the amount of services provided and can influence payments
by increasing the prices charged to an insurer. - Answer -charge based payment least to greatest risk to healthcare providers. - Answer -least risk - charge based payment RBRVS Per procedure payment Bundled payment greatest risk - Capitation greatest and least financial risk for the hospital - Answer -greatest risk- cost based payment charge based payment DRG Payment Case rate Bundled Payment Payment based on a pre-determined amount for a specified service - Answer -case rate Payment based on billed charges or a percentage discount of charges - Answer -charge based Payment based on a patient's diagnosis - Answer -drg Payment based on a fixed amount per day - Answer -per diem Ambulatory Payment Classification (APC) and Resource-Based Relative Value Scale (RBRVS) are both approaches to which type of payment? - Answer -A. Per procedure The payment category that utilizes a payment based on a fixed amount per member per month (PMPM) is: - Answer -A. Capitation
showing a hysterectomy for a male patient is an obvious coding error since hysterectomies are not performed on male patients. the claim for payment (or bill) is referred to as the ------ - Answer - ANSI 837 Healthcare Claim Format, or more commonly as the 837 record. remittance advice sent from the health plan to the provider explaining the payment decision is also a standard ANSI format, referred to as the ANSI 835 Healthcare Claim Payment/Advice is called ------- - Answer -835 record. w at terms means: Upon receipt of the claim, the health plan will record the claim in its inventory of claims pending processing in a step known as claim logging. It is customary with the use of electronic billing for the health plan to send an electronic acknowledgment of the claim to the provider. - Answer -claim logging The steps required by the health plan to process the claim for payment is collectively referred to as - Answer -claims adjudication. what is the payment processing steps? - Answer -1. CLAIM LOGGING
- ELIGIBILITY
- ADJUDICATION
- REMITTANCE Kate prepares claims for Palm Coast Orthopedics. Which of the following items would not be needed to be in order for her to send a clean claim? - Answer -B. Copies of the patient's previous medical records
Ryan is reviewing the net days in receivables data and noted that it has increased in the past month. Which of the following would be unimportant in determining why net days in receivables have increased over the past month? - Answer -The amount of time required for a new patient to get an appointment has no bearing on why net days in receivables have increased. The combined activities of pre-visit, during-visit, post-visit are known collectively as the: - Answer -A. Revenue cycle part of the process for clean review by a payer - Answer - Adjucation cycle Which of the activities below is not a part of the pre-visit portion of the revenue cycle? - Answer -C. Coding -coding occurs when the patient recieves care Which of the terms below represent the payer's steps involved in payment processing (claims adjudication)? - Answer -A. Claims logging, eligibility, adjudication, remittance _____ the intentional deception or misrepresentation of facts for gain. _____ carries criminal penalties. The burden of proof is high. (beyond reasonable doubt) - Answer -fraud ________ involves unintentional actions (errors) that are inconsistent with accepted, sound medical, business or fiscal practices. Abuse carries civil monetary penalties. The burden of proof is lower (preponderance of evidence) - Answer -abuse What is the goal of the compliance program? - Answer -to prevent fraud and abuse What is a chief enforcement vehicle of the federal govenment that allows the US Department of Health and Human Services to
Which of the following is NOT a law or regulation with which healthcare entities must comply? - Answer -CHIP (Childresns Health Insurance Program) provides health insurance to eligible children. This program is administered by the CMS and individual states What term is: The sources of cash given here (working capital management) - Answer -cash s the definition shows, working capital is not the same as cash. It is, rather, the surplus of cash- near-cash items such as accounts receivable and liquid short-term investments, over current obligations. Working capital management entails not only keeping working capital levels adequate for day-to-day operations but also maximizing available cash. - Answer - Prairie Family Care currently has a contract with Premier Health Plan to provide primary healthcare services to about 5, Premier members. Prairie has been paid 75% of charges for services but the contract will expire soon. Which of the following items represents a potential risk to Prairie Family Care if they accept capitation from Premier? - Answer -. Potential losses from increases in service utilization Charles Medical Center is interested in forming an Accountable Care Organization (ACO) with the Medicare program. Which of the following would be a priority for Charles Medical Center in forming a Medicare ACO? - Answer -A. Develop information systems As part of its strategy to become a low-cost, high-value provider that is attractive to health plans in the community, Valley Medical Center is exploring use of bundled payments in a contract with Amalgamated Health Plans. Valley Medical Center has operated
in a fee-for-service relationship with Amalgamated for the past twenty years, and has been paid on DRG and case rates during that time. Physicians in the community have admitted patients to the medical center and billed Amalgamated for their services. What areas should Valley Medical Center be attentive to in accepting bundled payments? - Answer -D. Identifying an equitable allocation of bundled payments among providers under the contract Which of the following describes the organization of primary care providers into a coordinated team to meet a patient's healthcare needs? - Answer -medical home The Affordable Care Act encourages providers to form entities called _________ which encourages them to work together to keep patients healthy. - Answer -ACO's is a payment and care delivery model, included in the affordable care act that ties provider reimbrusements based on quality metrics and expected cost reductions for the care of a defined population of patients Which of the reimbursement models below establishes a single prospective rate to all providers involved in a patient's care for the providers to divide equitably among themselves? - Answer - bundled payment are payments for specific healthcare services that are intended to be shared among treatement care teams What are the drivers of consumerism - Answer -1. availiability of information about diseases, treatments, physicians, and other health professionals on the internet
What is measured A process to protect the accuracy of such data Once this strategy is established, management must decide what metrics will be monitored. In some cases, the metrics monitored will be dictated by government regulators or private health plans. Also, the organization may want to measure other metrics that indicate progress toward strategic objectives. - Answer -Data strategy For business intelligence data to be useful, it must be available to decision-makers in time for them to take action on it. Clinical measures indicating the quality of patient care should be reported as frequently as possible (almost in real time if possible). Other metrics, such as performance on a capitation contract or income, do not need to be reported as often. A schedule of priorities for the business intelligence function should be established so that managers know when to expect information. - Answer -Data availiability A final critical element in business intelligence, particularly in health [1] care, is a process for maintaining the integrity of data. Data integrity is important not only for accurate reporting of clinical data that could influence patient care, but also for evaluating the costs of care under fixed or prospective payment methodologies. As healthcare information systems become more sophisticated, the amount of data available is increasing rapidly. Business intelligence personnel must closely monitor data accuracy, implement data integrity checks and work with clinical and administrative system users to address user error that could compromise data quality. - Answer -data integrity Karen White is Chief Financial Officer of Midwestern Health Plan. Karen and the CEO have agreed to implement a business intelligence function in the Plan. They want to gain a better
understanding of payments and quality outcomes. What items should Karen consider as she begins to implement this function at Midwestern? - Answer -A. Bring financial and clinical staff together to plan and execute analyses for the plan There are three steps in implementing business intelligence. Which of the groups of steps below represent these three steps? - Answer -A. Data strategy, data availability, data integrity Payment in this definition of value is the "amount paid by all purchasers of healthcare, including the insurer and patient." - Answer -payment for care Quality in this context is defined as a "composite of clinical outcomes, safety and patient experiences with healthcare services." - Answer -Healthcare quality Mary Jones is CFO of Island Health System. She and the system CEO believe that it is time for the system to start focusing on value-based payments with health plans in the community. To do so, they will have to shift the way the system sets its strategic objectives. Which of the following statements best describes the changes needed at Island Health System? - Answer -B. Reduce emphasis on increasing volume and increase focus on demonstrating high-quality outcomes and patient satisfaction Essential elements of the cooperative relationship between clinical and financial staff include: - Answer --common set of objectives -agreement on communication strategies -sense of trust and transparency between the two disciplines Bob Garcia is CEO of La Vida Medical Center and has just ended a meeting with his Chief Financial Officer and Chief Medical Officer. The discussion focused on the need to begin analyzing
