Reimbursement Flashcards
6 cards from real CBCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Reimbursement flashcards as text
What is the Ambulatory Payment Classification (APC) system?
Answer: A prospective payment system Medicare uses to reimburse hospital outpatient services, grouping procedures by clinical similarity and resource use
APCs are the payment groups used under the Hospital Outpatient Prospective Payment System (HOPPS). Each APC has a fixed payment rate based on the average resource costs of procedures within that group.
What is a value-based care reimbursement model?
Answer: A model that ties provider reimbursement to the quality and outcomes of care rather than the volume of services delivered
Value-based care models link reimbursement to quality metrics, patient outcomes, and efficiency rather than the quantity of services. Examples include ACOs, bundled payments, and pay-for-performance programs.
What does 'assignment' mean in Medicare billing?
Answer: A provider's agreement to accept the Medicare-approved amount as payment in full and not bill the patient beyond the applicable cost-sharing amounts
When a provider accepts assignment, they agree to accept the Medicare fee schedule amount as the full payment, collecting only the applicable deductible and coinsurance from the patient.
What is the purpose of the Outpatient Code Editor (OCE) in Medicare billing?
Answer: To process and edit Medicare outpatient hospital claims for compliance before payment under HOPPS
The OCE is a software system that edits Medicare outpatient hospital claims (UB-04) to ensure compliance with HOPPS billing rules, checking for correct CPT/HCPCS codes, revenue codes, and modifier usage.
What is a fee-for-service (FFS) reimbursement model?
Answer: A traditional payment model where providers are paid a separate fee for each service performed
Fee-for-service is the traditional model where providers receive a separate payment for each individual service rendered. Volume of services drives revenue rather than quality or outcomes.
What are relative value units (RVUs) used for in physician payment?
Answer: To measure a physician's productivity and calculate Medicare payment based on the complexity and resource intensity of services
RVUs measure the relative work, practice expense, and malpractice risk associated with a physician service. The Medicare Physician Fee Schedule payment is calculated by multiplying total RVUs by a conversion factor.