(02.07 LC)What was the outcome of the landmark Supreme Court…

Questions

(02.07 LC)Whаt wаs the оutcоme оf the lаndmark Supreme Court case Plessy v. Ferguson?

Fill in the blаnks belоw by cаlculаting dоllar amоunts where indicated or using this Word Bank (some words will not be used): acutely ill after before chronically ill chronically fatigued divided fair and accurate healthy high-quality most of multiplied patient profitable prompt prospective retrospective summed third-party payer 1.   Define prospective reimbursement. How is this methodology different from retrospective reimbursement?        Prospective reimbursement is a type of reimbursement in which the [BLANK-1] establishes the payment rates for healthcare services in advance for a specific time period. This is different from retrospective reimbursement because in retrospective reimbursement methodologies the total reimbursement amount is unknown until [BLANK-2] the healthcare services have been delivered.  2.   Calvin saw his PCP, Dr. Washington, because he had a fever and a sore throat. Dr. Washington ordered and performed a rapid strep test. Calvin’s test was positive, and he was diagnosed with streptococcal pharyngitis (strep throat). Dr. Washington wrote Calvin a prescription for amoxicillin to treat the pharyngitis. Dr. Washington submitted the following charges to Calvin’s insurance company, Super Payer: Clinic visit, level 2: $145 Rapid strep test: $50 Dr. Washington’s practice has a contract with Super Payer and the reimbursement methodology is a fee schedule. The fee schedule rate for a level 2 clinic visit is $70 and the fee schedule rate for a rapid strep test is $10. What is the total reimbursement Dr. Washington will receive for Calvin’s office visit?       The total reimbursement is [BLANK-3]. Enter a dollar sign and the dollar and cents amount like this: $9,999.99 3.   Super Payer has a contract with Community Hospital to provide inpatient care for their beneficiaries. They have agreed to a per diem reimbursement methodology. ICU days are reimbursed at $5,000 per day and medical bed days are reimbursed at $3,500 per day. Community Hospital submitted a claim for a six-day LOS. Two of the six days were ICU days and four of the six days were medical bed days. What is the total reimbursement owed to Community Hospital for this admission?       The total reimbursement is [BLANK-4]. Enter a dollar sign and the dollar and cents amount like this: $9,999.99 4.   Super Payer has a contract with Memorial Hospital for inpatient surgical admissions. They have agreed to a case rate methodology for these admissions. The case rate for a coronary artery bypass graft surgical admission is $28,500. Memorial Hospital submitted claims for the following admissions: Admission # Surgery LOS Charges  Cost 123 Coronary artery bypass graft 5 $78,050 $27,317 124 Coronary artery bypass graft 6 $84,400 $29,540 126 Coronary artery bypass graft 5 $79,450 $27,808 What is the total reimbursement Memorial Hospital will receive for each admission?       Memorial Hospital will receive $28,500 for each admission. Case rate is a [BLANK-5] reimbursement methodology. The reimbursement rate does not increase or decrease based on actual charges or actual cost of care. 5.   Dr. O’Neil’s physician practice has a PMPM contract with super Payer to provide primary care services. Super Payer uses a risk adjustment model to determine the PMPM amounts. The beneficiary risk score breakouts are provided below:      Number of Beneficiaries Risk Score Level PMPM Amount   100 1 – 1.00 risk score $200.00   135 2 – 1.25 risk score $250.00   150 3 – 1.50 risk score $300.00   125 4 – 1.75 risk score $350.00     90 5 – 2.00 risk score $400.00 TOTAL 600           How much reimbursement will Dr. O’Neil’s physician practice receive each month from Super Payer to provide primary care for the 600 beneficiaries?       The monthly reimbursement total is [BLANK-6]. Enter a dollar sign and the dollar and cents amount like this: $9,999.99 6.   What is the main goal of the CMS-HCC risk adjustment model?       The main goal of the CMS-HCC risk adjustment model is to provide [BLANK-7] payments while rewarding efficiency and [BLANK-8] care for Medicare’s [BLANK-9] population. 7.   Describe how diagnosis coding impacts reimbursement under the CMS-HCC risk adjustment model.       Diagnosis codes are used to determine the patient’s health status. The diagnoses included in the HCC model are assigned risk scores. The risk scores for a patient’s diagnoses are [BLANK-10] to determine the patient’s total health status risk score. This score is used to adjust the reimbursement rate. In essence, the reimbursement rate is customized based on the patient’s health status. 8.   Super-ACO had benchmark expenses of $2.5M and performance year expenses of $2.2M. If the shared saving percentage is 50 percent, how much shared savings would Super-ACO receive?       The shared savings amount Super-ACO would receive is [BLANK-11]. Enter a dollar sign and the dollar and cents amount like this: $9,999.99  9.   Super-ACO is deciding whether to convert to a two-sided risk for the next year. The shared saving rate is 75 percent and the shared loss rate is 30 percent for the track that is under consideration. Estimate the gain for the two-sided risk model if the actual expenses for the next year are 10 percent below the benchmark of $2.5M.       The estimated gain for Super-ACO is [BLANK-12]. Enter a dollar sign and the dollar and cents amount like this: $9,999.99 The calculation is ($2,500,000-$2,250,000) × 0.75. 10. Super-ACO is deciding whether to convert to a two-sided risk for the next year. The shared saving rate is 75 percent and the shared loss rate is 30 percent for the track that is under consideration. Estimate the loss for the two-sided risk model if the actual expenses for the next year are 10 percent above the benchmark of $2.5M.       The estimated loss for Super-ACO is [BLANK-13]. Enter a dollar sign and the dollar and cents amount like this: $9,999.99