CRCR Claims Processing and Reimbursement 3

Question 1

What is the global period in Medicare surgical billing and how does it affect reimbursement?

Accepted Answer

The defined post-operative period during which follow-up care is included in the surgical fee and cannot be billed separately

Answer

During the global period of 10 or 90 days depending on the surgery, post-operative care is bundled into the original surgical payment.

Question 2

What does it mean when a claim is pended by a payer?

Accepted Answer

The claim is being held for additional review or information before adjudication can be completed

Answer

A pended claim is in a suspended state awaiting additional information clinical review or coordination of benefits resolution before the payer can complete adjudication.

Question 3

What is capitation in managed care reimbursement?

Accepted Answer

A fixed monthly payment per enrolled member that covers all services in a defined scope regardless of utilization

Answer

Capitation pays a fixed amount per member per month regardless of services used transferring utilization risk to the provider.

Question 4

What is a provider-preventable condition in hospital billing?

Accepted 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

Answer

CMS does not provide additional payment for hospital-acquired conditions that are deemed provider-preventable incentivizing quality improvement.

Question 5

How does the Medicare Advantage reimbursement model differ from traditional Medicare fee-for-service?

Accepted 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

Answer

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.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Claims Processing and Reimbursement 3