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Exam 6: Financial Management: Insurance and Billing Functions

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Question 1

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Explain the fee-for-service reimbursement system as it compares to the reimbursement model used as a result of the Affordable Care Act (ACA).

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The fee-for-service reimbursement system is a traditional model in which healthcare providers are paid for each service they provide to a patient. This means that the more services a provider delivers, the more they get paid, regardless of the outcome or quality of care. This system has been criticized for incentivizing overutilization of services and driving up healthcare costs. On the other hand, the reimbursement model used as a result of the Affordable Care Act (ACA) focuses on value-based care. This model emphasizes quality of care and patient outcomes over quantity of services provided. It includes initiatives such as accountable care organizations (ACOs) and bundled payments, which aim to reward healthcare providers for delivering high-quality, cost-effective care. Under the ACA, healthcare providers are incentivized to focus on preventive care, care coordination, and managing chronic conditions to keep patients healthy and reduce the need for costly interventions. This shift towards value-based care is intended to improve the overall quality of healthcare while also controlling costs. In summary, the fee-for-service reimbursement system rewards volume of services, while the reimbursement model under the ACA emphasizes value and quality of care. The ACA's model aims to align incentives to promote better health outcomes and reduce unnecessary healthcare spending.

Question 2

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ICD-10-CM/PCS was implemented because

A) the American Medical Association has requested it.
B) ICD-9-CM no longer meets the needs of healthcare organizations.
C) it is already in use in Canada.
D) ICD-9-CM is out of print.

E) C) and D)
F) B) and D)

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Question 3

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Philip James has been a patient at Greensburg Medical Center for three years. During that time, he has been seen twice for annual physical exams, three times for ear infections, and four times for follow-up of his hypertension. How many encounters does Mr. James have at Greensburg Medical Center?

In a physician's office, procedures and services are converted into numeric form using which coding system?

In the Superbill Summary shown, code 80053 is what type of code?

Knowingly billing for services that are not medically necessary or that did not happen at all is

Which of the following is a true statement about ICD-10-CM/PCS?

Which of the following is not part of a paper encounter form (Superbill) ?

In many managed care plans, patients are responsible for paying a portion of the charges (fixed amount) at the time services are rendered. This is known as the

Of the following, which is not a reason that the United States did not implement ICD-10 at the time other countries did?

Coding practices that are inconsistent with typical practice are known as

Converting narrative diagnoses and procedures into numeric form is known as

Some insurance plans will pay for certain services and some will not. Explain this concept and give an example.

The coding system that is used to code services and procedures in a physician's office is _____________.

Roberta is going over the form with a patient; the form includes such information as the name of the patient, the provider's name and NPI number, the date of the visit, numeric codes corresponding to the patient's diagnoses and procedures performed that day. This form is called a Superbill and is otherwise known as what?

Nick Malone underwent an appendectomy by Dr. Lopez on September 5. Dr. Lopez documented appendicitis as Mr. Malone's diagnosis. The diagnosis was documented

Describe accounts receivable.

The coding system used in illustrating the tangible items such as supplies is

Which of the following is a true statement about using practice management (PM) software for an office's claims management process?

Roberta is a billing coordinator at Greenway Medical Center. She is in the process of determining whether a patient is covered by insurance, whether a co-payment is due, and whether the patient has met his deductible. What function is Roberta performing?