Claims Processing and Reimbursement Flashcards
6 cards from real CRCR practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Claims Processing and Reimbursement flashcards as text
What is the global period in Medicare surgical billing and how does it affect reimbursement?
Answer: The defined post-operative period during which follow-up care is included in the surgical fee and cannot be billed separately
During the global period of 10 or 90 days depending on the surgery, post-operative care is bundled into the original surgical payment.
What does it mean when a claim is pended by a payer?
Answer: The claim is being held for additional review or information before adjudication can be completed
A pended claim is in a suspended state awaiting additional information clinical review or coordination of benefits resolution before the payer can complete adjudication.
What is capitation in managed care reimbursement?
Answer: A fixed monthly payment per enrolled member that covers all services in a defined scope regardless of utilization
Capitation pays a fixed amount per member per month regardless of services used transferring utilization risk to the provider.
What is a provider-preventable condition in hospital billing?
Answer: A condition or complication that occurs during the hospital stay that reasonable care could have prevented for which Medicare does not pay additional amounts
CMS does not provide additional payment for hospital-acquired conditions that are deemed provider-preventable incentivizing quality improvement.
How does the Medicare Advantage reimbursement model differ from traditional Medicare fee-for-service?
Answer: Under Medicare Advantage, private insurers are paid a risk-adjusted capitated rate by CMS to manage benefits for enrolled beneficiaries often using their own provider networks and utilization management tools
Medicare Advantage uses private insurers who take on the financial risk of managing Medicare benefits often with more aggressive utilization management and different reimbursement structures.
What is the significance of data benchmarking in revenue cycle performance management?
Answer: Comparing an organization's KPIs against industry standards or peer organizations to identify performance gaps and opportunities
Benchmarking reveals whether performance is truly excellent by comparing against external standards and peers.