Chapter 1_workbook exercises
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Principles of Healthcare
Reimbursement and
Revenue Cycle
Management
Eighth Edition
Student Workbook
Chapter 1
Healthcare Reimbursement and
Revenue Cycle Management
Copyright ©2024 by the American Health Information Management Association. All rights reserved.
Principles of Healthcare Reimbursement and Revenue Cycle Management
Student Workbook
Chapter 1
1.
Key Term Matching
Match the key term to the correct definition.
Key Term
Answe
r
Definition
a. Beneficiary
d.
Individual who purchases health insurance coverage
b. Guarantor
g.
Group of individuals or entities who have a similar risk of loss
c. Insurance
h.
Insurance company or health agency that pays the provider for the care or services provided to the patient
d. Policyholder
a.
An individual who is eligible for benefits from a health plan
e. Premium
b.
Person who is responsible for paying the bill for healthcare services
f. Reimbursement
e.
Amount of money that must be periodically paid to a health insurance company in return for healthcare coverage.
g. Risk pool
c.
Reduction of a person’s exposure to risk of loss by having another party assume the risk
h. Third-party payer
f.
The amount paid to a healthcare provider for services provided to a patient.
2.
Understanding revenue cycle management basics (Level 2—Understanding)
An introduction to revenue cycle management (RCM) is provided in chapter 1. The following table includes the key terms for RCM. Translate each concept into everyday, nontechnical language.
RCM Concept
Translation
Revenue integrity
It determines that an insurance claim is legitimate. It reflects all services and supplies and is error free. It also follows contract requirements, regulations, and laws.
Revenue cycle
A regular set of tasks and activities that produce the amount that is paid to a healthcare provider for the services they provide to a patient.
Integrated revenue cycle
It provides structure and coordination between physicians and the insurers to reduce costs, have Copyright ©2024 by the American Health Information Management Association. All rights reserved.
Principles of Healthcare Reimbursement and Revenue Cycle Management
Student Workbook
Chapter 1
consistency, and provide a shared focus of goals between financial and non-financial units.
3.
US Healthcare Business Model—Understanding the Relationships between Patient, Employer, Third-Party Payer and Provider (Level 3—Applying)
Figure 1.3 provides an illustration of the US healthcare business model. In chapter 1, the relationships among the patient, employer, third-party payer, and provider are discussed. Assign the transactions in the following patient scenario to the appropriate relationship line
displayed in figure 1.3 of the book. Monique is an assistant director at Beautiful Outfits, a large fashion company. Monique purchases health insurance through her employer. As part of her benefit
package, Beautiful Outfits pays 70 percent of the premium, and Monique paysthe remaining 30 percent via payroll processing. Monique’s insurance company is Super Payer. Monique joined a kickball league and sprained her ankle at the last game. She went to her primary care provider, Dr. Chen, for care. Upon registration, she paid a $25 cost sharing amount. Dr. Chen evaluated and diagnosed Monique’s sprained ankle, and she was instructed to follow RICE (rest, ice, compression, and elevation). Dr. Chen submitted an invoice for reimbursement to Super Payer. Super Payer reimbursed Dr. Chen $80 for the office visit. Complete the following table by assigning the appropriate relationship as shown in figure 1.3, US healthcare business model, to the transactions found in the clinical scenario.
Instructions: Enter the NUMBER (1, 2, 3, 4, or 5) from Figure 1.3 that corresponds to the line connecting the two entities in the relationship.
Transaction
Relationship #
from Figure 1.3
a.
Monique paying her share of health insurance premium via payroll processing.
4
b.
Dr. Chen evaluated and diagnosed Monique with a sprained ankle.
1
c.
Beautiful Outfits pays 70 percent of Monique’s health insurance premium.
3
d.
Dr. Chen submits invoice to Super Payer for Monique’s clinic visit. 2
e.
Monique pays her cost-sharing to Dr. Chen.
1
Copyright ©2024 by the American Health Information Management Association. All rights reserved.
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Principles of Healthcare Reimbursement and Revenue Cycle Management
Student Workbook
Chapter 1
f.
Super Payer reimburses Dr. Chen $80.00 for Monique’s office visit.
2
Copyright ©2024 by the American Health Information Management Association. All rights reserved.