Reimbursement Exam 1-Part 1

SNF PPS - Sklilled Nursing Facilites Perspective Payment System - a per-diem reimbursment system implemented in July 1998 for cost (routine, ancillary, and capital) assoicated with covered skilled nursing facilty services furnished to Meidcare Part A beneficiaries

Hospital outpatient prospecitive payment system (HOPPS). The classification is a resource-based resource-based reimbursment system. The payment unity is the ambularoty payment classification group

a case-mix-adjusted classification system based on Min Data Set assessments and used by skilled nursing facilities

Home Health Prospective Payment System - The reimbursement system developed by the centers for Medicare and Medicaid Services to cover home health services provided to medicare beneficaries

Outcomes and Assesment Information Set - A standard core assessment data tool developed tomeasure the outcomes of adult patients receiving home health services under the medicare and medicaid programs

Home Assessment Validation and Entry - a type of data-entry software used to collect Outcome and Assessment Information Ses (OASIS) data and then transmit them to stat databases: improts and exprots data in standard OASIS record format, maintains agency/patient/emplouee information, enforces data integrity through rigerous edit checkts, and provides comprehensive online help

Home Health Resource Group - a classification system with 80 home health episode rates established to support the prosepective reimbursement of covered home care and rehanilitation services provided to Medicare beneficaries during 60-day episode of care

A health plan that processes Part B Claims for services by physicians and medical suppliers (i.e. Blue Shield plan in a state)

•  Medicare Administrative Contractors - administor Medicare part A and Part B as of 2011- They will replace the carries and fiscal intermedaries
•  - preform medical revies on both prepayment and postpayment basis to ensure that the servicesa are covered correctly coded, and reasonable and necessary for the acute patient and the  long-term care hospital settings

 an organization that contract with the centers for medicare and medicaid services to serve as teh financial agent between providers and the fereral and medicaid services to serve as teh financial agernt between providers andd the federal government in the local administration of medicare part B claims

Quality Improvment Organization - an organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information  completenes adequcy and quality of care and appropirateness of prospective payments for outlier cases and nonemergent use of the emergancy room  until 2002 called peer review organization

American National Standard Institute - the organization that accredit all the US standards development organizations toensure that they are following due process in mulgating standards

Ambularoty Surgery Center - a disinct entity that operates exclusively for the prupose of funishing outpatient surgical services to patients

A committee of the national standards institue that develops and maintains standards for the electronic exchange of business transactions such as 837 - health Care Claim 835 - health care claim payment/advice and others

Electronic Data Interchange - a standard transmission format using strings of data for business information communicated amoung the computer systems of independent organizations

Coordination of Benifits - the electronic transaction of claims and/or payment information from a healthcare provider to a health plan for the purpose of dermining relative payment responsibilites

sent electronically to the provider to list the patient and the payment for each. In addition, the remittance advice lists rejections, denials, allowances, and other details. From teh remittance advice, providers dertermine how much money they must write off based on the contracted allowances, negociated discounts or fee schedules

EOB - a report that is ent from a healthcare insurer to the policyholder (certificate holder or subscriber); it explains how the healthcare insurance company determined its paymen t for the healthcare services

a summary sent to the patient form Mediare that summarizes all services provided over a period of time with an explanation of benefits provided

an intentional representation that an invidual knows to be false or does not believe tobe true and makes, knowing that the representation couldresult in some unautorized benefits to  himself/herself or some other person (i.e billing for a service that was not rendered)

Occurs when a healthcare provider unknowingly or unintentionally submits and inaccurate claim to for payment. generally from an unsound medical business or fisical practices that directly or indriectly result in unneccessay costs tothe medicare program.

Local Coverage Determiation - an example of a topic that should be covered under the Coding Compliance - An LCD, as established by Section 522 of the Benefits Improvement and Protection Act, is a decision by a fiscal intermediary or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act

an analysis process that is based on comparisons

compensation or repayment for health services

Multipurpose, nonprogit service organization for physcianss and other healthcare provider5s at the local and county level; as managed care organzaions, medical foundations have established preferred provider organizations exclusive provider organizations and magagement services organizations with emphasises on freedom of choice and preservation of the physician patient relationship

Physican-hospital organization - an integrated delivery system formed by hospitals andphysicians (usually through managed care contracts) that allows for cooperative activity but permits participants to retain some level of independence

 MSO - an organization usually owned by a group of physicians or a hospital, that provides administrative and support services to one or more physiscians group practices or small hospitals

Local Medical Review Policy