Healthcare Settings, Reimbursement, and Regulatory Compliance Flashcards

Which Medicare part primarily covers outpatient therapy services and physician visits?

Answer: Part B

Medicare Part B is medical insurance covering outpatient services, including outpatient therapy.

Medicare Advantage plans, offered by private insurers approved by Medicare, are known as:

Answer: Part C

Medicare Part C (Medicare Advantage) lets private plans deliver Medicare benefits.

Which statement best describes Medicaid?

Answer: A jointly funded federal-state program for eligible low-income individuals

Medicaid is a means-tested program jointly funded by federal and state governments and administered by states.

In a capitated managed care contract, the provider is paid:

Answer: A fixed amount per member per month regardless of services used

Capitation pays a set per-member-per-month amount, shifting financial risk to the provider.

Before admitting a patient to a rehab program, a managed care plan requires the facility to obtain approval. This process is called:

Answer: Prior authorization

Prior (pre-) authorization is payer approval obtained before services are delivered.

A patient pays 20% of the Medicare-approved amount for an outpatient service after meeting the deductible. That 20% is called:

Answer: Coinsurance

Coinsurance is a percentage of the approved cost paid by the patient, whereas a copayment is a fixed dollar amount.

Which code set is used to document a patient's diagnosis on claims in U.S. healthcare?

Answer: ICD-10-CM

ICD-10-CM codes report diagnoses, while CPT codes report procedures and services.