MHA Healthcare Economics and Reimbursement 3

Question 1

In healthcare finance, the difference between a hospital's charges and the actual payments received from payers is called:

Accepted Answer

Contractual adjustment (or allowance)

Answer

Contractual adjustments represent the write-off between gross charges and the negotiated or allowable payment accepted from payers, and are reflected on the income statement.

Question 2

Which coding system is used in the United States to classify diagnoses and inpatient procedures for billing and data purposes?

Accepted Answer

ICD-10-CM/PCS

Answer

ICD-10-CM (Clinical Modification) is used for diagnosis coding and ICD-10-PCS (Procedure Coding System) for inpatient procedures, both required for hospital billing in the U.S.

Question 3

Medicare Part A primarily covers:

Accepted Answer

Inpatient hospital stays, skilled nursing facilities, hospice, and some home health care

Answer

Medicare Part A is the hospital insurance component, covering inpatient hospital care, skilled nursing facility stays (post-qualifying inpatient stay), hospice, and some home health services.

Question 4

A Federally Qualified Health Center (FQHC) receives what type of enhanced reimbursement from Medicare and Medicaid?

Accepted Answer

A Prospective Payment System (PPS) rate based on encounter type

Answer

FQHCs receive a PPS all-inclusive encounter rate from Medicare and Medicaid that covers all primary care services provided during one visit, regardless of services rendered.

Question 5

The medical loss ratio (MLR) rule under the Affordable Care Act requires that health insurers spend what minimum percentage of premiums on clinical care and quality improvement?

Accepted Answer

80% for individual/small group and 85% for large group markets

Answer

The ACA mandates an 80/85 MLR rule: individual and small group insurers must spend at least 80% of premiums on care; large group insurers must spend at least 85%, with rebates owed to enrollees if not met.

MHA - Master of Healthcare Administration Practice Test

MHA - Master of Healthcare Administration Practice Test

MHA Healthcare Economics and Reimbursement 3