Adult-Gerontology Clinical Nurse Specialist (CNS) Practice Exam

What payment system does Medicare use for covering claims?

1. Retrospective payment scale

2. Apportionment

3. Prospective payment scale

4. Resource-based relative value scale

The correct answer is: Resource-based relative value scale

Medicare primarily utilizes the Resource-based Relative Value Scale (RBRVS) to cover claims, particularly for physician services. This payment system assigns a value to different services and procedures based on the resources required to provide them, including the cost of time, skill, and intensity of services. This approach helps determine the payment amount for each service by establishing a standard that reflects the complexity and effort involved. The RBRVS is designed to be fair and transparent, allowing for efficient processing of claims while ensuring that providers are adequately reimbursed for their services. It supports a predictable payment structure that can adjust based on geographic location and other factors that might influence the cost of delivering care. In contrast, the other options refer to different payment methodologies not primarily used by Medicare for covering claims. Retrospective payment systems involve payment after services are delivered, often based on actual costs, while prospective payment systems set a predetermined payment based on diagnosis or service prior to delivery. Apportionment generally refers to the distribution of costs and is not a specific payment system for Medicare claims. Thus, the RBRVS is the most accurate description of the payment system used by Medicare.