Author: Anonymous

What is the main goal of the CMS-HCC risk adjustment model?

When a provider bills separately for procedures that are a part of the major procedure, this is called

CMS uses this reimbursement methodology when they contract with Medicare Advantage Payers to care for Medicare beneficiaries under Medicare Part C.

CMS uses which reimbursement methodology for inpatient psychiatric facility services payment system because a specific payment rate is established for each day of the admission?

Coinsurance payments are paid by the _______ and determined by a specified percentage

Giant ACO has agreed to a shared savings rate of 65 percent and a shared loss rate of 40percent with CMS. Giant ACO participates in a __________ risk agreement.

Which of the following statements about retrospective reimbursement is false?

      1. Evie is enrolled in Medicare Parts A and B. She recently started PT for hip pain. The approved amount per visit is $125. How much does Evie owe in cost sharing per visits. Evie has already met her outpatient deductible. (Blank 1) 2. Clyde is enrolled in Medicare Parts A and B. He had a knee arthroscopy in January. This is Clyde’s first health encounter for the year so he has not met his deductible. The approved amount for his surgeon is $550. How much does Clyde owe in cost sharing for the surgeon’s services. (Blank 2)

One managed care concept that has carried over to most insurance plans is utilization management. A key component of utilization management is utilization review. Describe utilization review. Provide an example of when utilization review would be used.

Medicaid is a joint program between _________and _________governments?