The Medicare program has many rules and regulations. This quiz will cover some of the more common information about general Medicare coverage and the Risk Adjustment Program.
Medicare Coverage / Risk Adjustment Quiz
This quiz will evaluate your knowledge of Medicare Coverage. There is one correct answer for each question and no time limit on this quiz.
Each correct answer is worth one point. Good luck.
Disclaimer - All answers are felt to be correct. However, if you disagree, please research the issue. Mistakes happen.
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The official US government website for Medicare is:
This type of claim occurs when the claim cannot be processed due to technical errors, invalid, or missing info, or claim submission instructions not being followed.
Assume that an 84 year old patient (Joan) went to the Emergency Department (ED) and was formally admitted to the hospital with a doctor’s order as an inpatient for 3 days. Joan was discharged on the 4th day. Assuming that she needs skilled nursing care, will her skilled nursing facility (SNF) stay be covered by Medicare?
No. Joan did not meet the requirements for a covered SNF stay.
Yes. Joan met the 3-day inpatient hospital stay requirement for a covered SNF stay.
Medicare's Risk Adjustment model is one that uses reported diagnoses in the current year to predict healthcare expenditures in the following year. This type of model is called:
With this type of Medicare fraud, the medical provider bills Medicare for unnecessary procedures, or procedures that are never performed; for unnecessary medical tests or tests never performed; for unnecessary equipment; or equipment that is billed as new but is, in fact, used.
In the Risk Adjustment program from CMS, it is possible for two different patients within the same geographic community to have different payment rates.
Question 8 Explanation:
The payment rate is based the amount of risk, or medical intervention, it will take to maintain the individual patient's health. For example, a patient with a chronic illness, such as diabetes, will likely take more medical intervention, than another patient without any chronic illness.
Assume that William, age 70 visited the Emergency Department (ED) and spent one day getting observation services. Then, William was formally admitted to the hospital as an inpatient for 2 more days, then discharged. Assuming that William needs skilled nursing care, will William's SNF stay be covered by Medicare?
Yes. William met the 3-day inpatient hospital stay requirement for a covered SNF stay.
No. Even though William spent 3 days in the hospital, he was considered an outpatient while getting ED and observation services. These days don’t count toward the 3-day inpatient hospital stay requirement.
This type of service would be provided to an outpatient Medicare patient by a non-physician practitioner. The supervising physician, however, must be present in the office and supervise the non-physician practitioner. This type of service can be billed to Medicare as:
Incident to service
Fee for service
Part A Medicare
Question 18 Explanation:
Source - www.Medicare.gov
This is a CMS payment method which provides a risk factor score for Medicare Advantage patients with chronic illness. This score reflects patient complexity and is used to calculate and adjust payments to providers.
Fee for service
Diagnosis Related Groups
In general, all of the following, except ________ are services that are NOT covered by Part A or B of Medicare.
routine eye care and eyeglasses
durable medical equipment
According to CMS, by using the Risk Adjustment Program, CMS is able to make appropriate and accurate payments for Medicare Advantage enrollees who have differences in:
Question 21 Explanation:
The "expected costs" are based upon the patient's risk. Patients with more serious and chronic diagnoses are more at risk than those without.
Which of the following is covered by Medicare?
Under Medicare Part B, the annual limitations on per beneficiary incurred expenses for outpatient therapy services are commonly referred to as:
Medicare's Hierarchical Condition Categories (HCC) model is based upon which coding system?
The Risk Adjustment (RA) program from Medicare is based on all of the following demographics except:
Most of the Medicare Prescription Drug Plans have a gap in coverage . This means there's a temporary limit on what the drug plan will cover for drugs. This temporary gap in prescription drug coverage is called:
Medicare Part D
out of pocket costs
the donut hole
Which of the services listed below is not covered by Part B of Medicare?
hospital outpatient care
home health care
doctor's office visits
In Medicare's Risk Adjustment program, risk adjustment scores are ______ for a patient with a greater disease burden.
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