Question

1. A hospital submitting an outpatient claim would use a UB-04 claim form. What source of coding information is used to report diagnosis codes? What source of coding information is used to report procedures?
2. What are the primary uses of financial information?
3. Is profit maximization the same thing as shareholder wealth maximization?
4. What are the objectives of not-for-profit (NFP) firms?
5. What are social responsibility and ethics as they relate to business-oriented organizations? How should social responsibility and ethics affect the decisions of even for-profit companies?
6. What is the main difference between the fee-for-service and capitation reimbursement methods?
7. For the following problems (as applicable), assume that the Medicare/patient split of payments is as covered in the book. Assume that the participating/non-participating and maximum allowable charge are as covered in the book. Ignore the patient's annual deductible. Use the following information to answer the question. Dr. Melissa Rose is trying to decide whether to be a Medicare-participating physician for the upcoming year. (Assume that her entire practice consists of Medicare patients or at least that her practice has slack capacity. Her Medicare patients do not displace non-Medicare patients.) Assume that her average charge is $120 (before Medicare's limiting charge is applied), for which the average Medicare-approved amount is $100. If she decides to be a non-participating physician, she expects to accept assignment 80% of the time. For the unassigned patients assume that she would set her charges at 110% of the Medicare-approved fee for a nonparticipating physician. Assume that her Medicare patient volume is not reduced if she chooses not to participate nor if she does not accept assignment. (Ignore bad debt and any other factors not presented here.)

Case Study: What will be Dr. Rose's average reimbursement per visit if she chooses to be a Medicare-participating physician? (This is the total from both Medicare and the patients.)

8. For the following problems (as applicable), assume that the Medicare/patient split of payments is as covered in the book. Assume that the participating/non-participating and maximum allowable charge are as covered in the book. Ignore the patient's annual deductible. Use the following information to answer the question. Dr. Melissa Rose is trying to decide whether to be a Medicare-participating physician for the upcoming year. (Assume that her entire practice consists of Medicare patients or at least that her practice has slack capacity. Her Medicare patients do not displace non-Medicare patients.) Assume that her average charge is $120 (before Medicare's limiting charge is applied), for which the average Medicare-approved amount is $100. If she decides to be a non-participating physician, she expects to accept assignment 80% of the time. For the unassigned patients, assume that she would set her charges at 110% of the Medicare-approved fee for a nonparticipating physician. Assume that her Medicare patient volume is not reduced if she chooses not to participate nor if she does not accept assignment. (Ignore bad debt and any other factors not presented here.)

Case Study: What will be Dr. Rose's average reimbursement per visit if she chooses to be a Medicare-participating physician? (This is the total from both Medicare and the patients.)

9. For the following problems (as applicable), assume that the Medicare/patient split of payments is as covered in the book. Assume that the participating/non-participating and maximum allowable charge are as covered in the book. Ignore the patient's annual deductible. Use the following information to answer the question. Dr. Melissa Rose is trying to decide whether to be a Medicare-participating physician for the upcoming year. (Assume that her entire practice consists of Medicare patients or at least that her practice has slack capacity. Her Medicare patients do not displace non-Medicare patients.) Assume that her average charge is $120 (before Medicare's limiting charge is applied), for which the average Medicare-approved amount is $100. If she decides to be a non-participating physician, she expects to accept assignment 80% of the time. For the unassigned patients assume that she would set her charges at 110% of the Medicare-approved fee for a nonparticipating physician. Assume that her Medicare patient volume is not reduced if she chooses not to participate nor if she does not accept assignment. (Ignore bad debt and any other factors not presented here.)

Case Study: Based strictly on the information presented here (ignore bad debt, patient mix differences, and other considerations not presented here), should she choose to be participating or non-participating if she wishes to maximize her total reimbursement for services?

10. A non-participating physician provides services to a Medicare patient who has total charges of $100 (before Medicare's limiting charge is applied). The physician does not accept assignment, charges the maximum allowable, and submits the claim to Medicare. Assume Medicare's approved schedule for these services is $80. What is the Medicare portion of the physician payment (which Medicare sends to the patient)? What is the patient's portion of the payment to the physician (net of the reimbursement from Medicare)?

Answer 1

What source of coding information is used to report diagnosis codes? What source of coding information is used to report procedures?

For diagnosis codes - ICD-10-CM

For Report procedures - HCPCS

What are the primary uses of financial information?

Evaluating the financial condition of an entity
Evaluating stewardship within an entity
Assessing the efficiency of operations
Assessing the effectiveness of operations
Determining the compliance of operation with directives

Is profit maximization the same thing as shareholder wealth maximization?

No, profit maximization does not take into consideration the time or risk dimensionsin the measurement of proft while shareholder wealth maximization does.

What are the objectives of not-for-profit (NFP) firms?

To serve the community in which it operates through the healthcare services it provides. Their focus is also on profit maximization, cost recovery, market incentives and market suppression.

What are social responsibility and ethics as they relate to business-oriented organizations? How should social responsibility and ethics affect the decisions of even for-profit companies?

Social responsibility is the concept that businesses have a duty to society and the environment and focuses on doing what is best for the well-being of society as a whole. In regards to ethics, this pertains to how companies conduct themselves in their practices and policies. How should social responsibility and ethics affect the decisions of even for-profit companies? Social responsibility and ethics should affect decisions in that companies are aware of society’s expectations of the services they are receiving and with having that understanding the company commits to doing what is right in regards to their operation and delivery of services offered.

What is the main difference between the fee-for-service and capitation reimbursement methods?

Fee-for-service methods of reimbursement are cost based, charge based, and prospective payment.Health services organizations and providers are paid per amount of services provided, the more servicesthey provide the more they get paid so basically, more services more money. On the other hand,capitation pays the provider a fixed amount per covered life per period, regardless of the amount ofservices provided.

Case Study Answers:

PLEASE LIKE THIS ANSWER, IT HELPS ME A LOT. THANK YOU!!!