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 Medicare Physician Fee Schedule (MPFS)?
Answer: A payment system used by Medicare to determine reimbursement for physician and outpatient services based on Resource-Based Relative Value Units (RBRVUs)
The Medicare Physician Fee Schedule determines payment for physician services using a formula based on Relative Value Units (RVUs) for work, practice expense, and malpractice, multiplied by a conversion factor.
What is a prospective payment system (PPS)?
Answer: A reimbursement method where predetermined fixed payments are made for services based on diagnosis or procedure categories
Under a prospective payment system, payment amounts are predetermined based on the patient's diagnosis or procedure category, encouraging efficiency and cost control.
What is a contractual adjustment in medical billing?
Answer: The difference between the provider's billed charge and the amount agreed upon in the payer contract (write-off)
A contractual adjustment is the amount written off because of an agreement between the provider and the payer. It represents the difference between the full charge and the contracted (allowed) rate.
What does DRG stand for and how is it used in hospital billing?
Answer: Diagnosis-Related Group — a classification system that determines fixed Medicare payment for inpatient hospital stays based on the patient's diagnosis and treatment
DRG (Diagnosis-Related Group) is the classification system Medicare uses to determine fixed payment amounts for inpatient hospital stays. Each DRG has a relative weight that determines the payment amount.
What is capitation in managed care reimbursement?
Answer: A fixed monthly payment per enrolled member made to providers, regardless of the number of services provided
Capitation is a payment model where providers receive a fixed monthly payment per enrolled patient (per member per month — PMPM) regardless of how many services that patient uses.
What is the purpose of the Medicare fee schedule's Geographic Practice Cost Index (GPCI)?
Answer: To adjust Medicare physician fee schedule payments to reflect the cost of providing services in different geographic areas
The GPCI adjusts each component of the RVU (work, practice expense, malpractice) to account for geographic differences in costs, ensuring fair payment across different regions of the country.