Which of the following statements about retrospective reimbursement is false?

Medicaid is a joint program between _________and _________governments?

One managed care concept that has carried over to most insurance plans is utilization management. A key component of utilization management is utilization review. Describe utilization review. Provide an example of when utilization review would be used.

Which of the following is not a limitation typically included in a health insurance policy?

Use the following excerpt from table 3.2, Part B Services 2020 1. Alona is enrolled in Medicare Parts A and B. She goes to the hospital seniors clinic for her arthritis. She had a regular visit in June when Dr. Proudfoot examined her, checked her medications, and suggested water aerobics. The approved amount for her visit is $230. Alona met her outpatient deductible in March. What is her cost sharing amount for the visit to Dr. Proudfoot? (Blank 1) 2. Sal is enrolled in Medicare Parts A and B. He goes to the hospital seniors clinic for congestive heart failure. He had a regular visit in November when Dr. Nauman examined him, checked his medications, and suggested a high fiber diet. The approved amount for her visit is $275. Sal met his outpatient deductible in February. What is his cost sharing amount for the visit to Dr. Nauman?

Which of the following is not a principle of revenue integrity?

Managed care plans control beneficiary choice of provider. On the continuum of control, which type of managed care organization has the most control and, therefore, has the greatest limitations on a beneficiary seeing a provider that is not in-network?

Medicare has four criteria to define medically necessary services. Which of the following is not one of the four criteria?

All of the following types of procedures and services typically require prior authorization except

1. Patient 72341 is admitted as an inpatient for delivery. Length of stay is three days. The charges for the encounter are $10,425.00. The cost of the encounter is $5,848.45. Which payer will reimburse the hospital the highest amount? (blank 1) 2. Patient 89423 is seen in the outpatient clinic at Happy Hospital for a pneumonia follow-up visit. The charges for the encounter total $135. Which payer will reimburse the hospital the lowest amount? (blank 2) 3. Patient 24571 is seen in the Occupational Therapy (OT) clinic for an initial evaluation of her carpal tunnel surgery recovery. The charges for the visit total $150. Which payer will reimburse the facility the highest amount? (blank 3) 4. Patient 62316 is admitted as an inpatient for hip replacement following a fall on ice in the school parking lot where he works as a teacher. During his admission, the patient received OT services post-surgery. The LOS was six days. The charges for the encounter are $135,000. Which payer will reimburse the hospital the highest amount? (blank 4) a. Payer A b. Payer B c. Payer C d. Payer D e. There is not enough information in the contract matrix to determine reimbursement for this encounter