Care Delivery and Reimbursement Methods

Question 1

A process by which a single case manager assists clients/support systems with all barriers to health, including those related to physical illnesses or mental health and substance use disorders (mental conditions). Handoffs among case managers and care providers are minimized, and total health outcomes for clients are the responsibility of each individual case manager

Answer 1

Integrated Case Management (ICM)

Question 2

The process of determining and documenting specific objectives, goals,
and actions designed to meet the client’s needs as identified through the
assessment process; action- oriented and time-specific.

Answer 2

Planning

Question 3

A holistic, person-centered approach to the management of healthcare and
services of a person with a complex, catastrophic, or life-altering condition or disability with the ultimate goal to promote and maintain the person’s good health, safety, well-being, and quality of life. It applies a consistent methodology for analyzing all of the actual present and potential future needs and their associated expenses dictated by the onset of a catastrophic disability through to the end-of-life expectancy

Answer 3

Life Care Planning

Question 4

An independent, nonprofit
organization that promotes healthcare quality through accreditation, education, and measurement programs. Its main mission focuses on promoting continuous improvement in the quality and efficiency of healthcare management through processes of accreditation and education. This organization offers a wide range of quality benchmarking services, validates the commitment of healthcare organizations to quality and accountability through accreditation, and ensures that all stakeholders
are represented in establishing meaningful quality measures for the healthcare industry

Answer 4

Utilization Review Accreditation Commission (URAC)

Question 5

A process of managing occupational and nonoccupational diseases with the aim of returning the disabled employee to a productive work schedule and employment.

Answer 5

Disability Case Management

Question 6

a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client’s health and human services needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes

Answer 6

Case Management

Question 7

The goals of case management are improving client’s ________, __________, ___________, and ____________ status.

Answer 7

clinical, functional, emotional, and psychosocial

Question 8

________ _______ are benefits in the form of payments rather than services. They are also known as fee-for-service benefits. Typically, the healthcare provider bills the patient, and the insurance company reimburses the patient later. The patient is free to choose his provider without restriction, but these policies are more expensive than managed care policies.

Answer 8

Indemnity benefits

Question 9

A surcharge that high-income people may pay in addition to their Medicare Part B and Part D premiums.

Answer 9

Income Related Monthly Adjustment Amount (IRMAA)

Question 10

A supplemental cost-sharing arrangement between the member and the insurer in which the member pays a specific charge for a specified service; may be flat or variable amounts per unit of service and may be for such things as physician office visits, prescriptions, or hospital services. The payment is incurred
at the time of service.
A set amount the patient pays each time a specific service is rendered.

Answer 10

Copayment

Question 11

A type of cost sharing in which the insured person pays or shares part of the medical bill, usually according to a fixed percentage.

Answer 11

Coinsurance

Question 12

A specific amount of money the insured person must pay for covered expenses before the insurance company begins paying.

Answer 12

Deductible

Question 13

With this type of reimbursement, each service rendered is priced separately. Providers are paid for each service performed, as opposed to capitation. Fee schedules are an example of this.

Answer 13

Fee-For-Service (FFS)

Question 14

Bundled payments, case rates, and prospective payment systems are examples of what type of reimbursement model (pays one predetermined amount, no matter the number or cost of services provided)?

Answer 14

Episode-of-care reimbursement model

Question 15

Rate of reimbursement that packages pricing for a certain category of services.
Typically combines facility and professional practitioner fees for care and services.

Answer 15

Case Rates

Question 16

A healthcare payment system used by the federal government since 1983 for
reimbursing healthcare providers/agencies for medical care provided to Medicare and Medicaid participants. The payment is fixed and based on the operating costs
of the client’s diagnosis.

Answer 16

Prospective Payment System (PPS)

Question 17

Both of these payment methodologies make a single comprehensive payment to healthcare providers to cover all services related to a treatment or condition.

Answer 17

Bundled/Case Rate
*bundled is used more often when referring to “bundling” physician and hospital charges or charges to multiple providers in multiple settings
*case rate is used when referring to a flat fee paid to the provider for a client’s treatment based on his diagnosis or presenting problem

Question 18

A patient classification scheme that provides a means of relating the type of patient a hospital treats to the costs incurred by the hospital. This term demonstrates groups of patients using similar resource consumption and length of stay. It also is known as a statistical system of classifying any inpatient stay into groups for the
purposes of payment. These groups may be primary or secondary; an outlier classification also exists. This is the basis of payment the CMS uses to pay hospitals for Medicare and Medicaid recipients. Also used by a few states for all payers and
by many private health plans (usually non-HMO) for contracting purposes. this predetermined amount is paid regardless of the actual cost of treating the patient. This approach provides a significant incentive for hospitals to decrease costs.

Answer 18

Diagnosis-Related Group (DRG)

Question 19

A diagnostic tool used to classify patients into distinct groups based on clinical characteristics and expected resource needs. This diagnostic determines the Case Mix Group (CMG) classification.

Answer 19

Inpatient Rehabilitation Facilities Patient Assessment Instrument (IRF-PAI)

Question 20

Each _______ ___ _____ has a relative weight that determines the base payment rate for inpatient rehabilitation facilities under the Medicare system.

Answer 20

Case Mix Group (CMG)

Question 21

An encounter-based classification system for outpatient reimbursement, including hospital-based clinics, emergency departments, observation, and ambulatory surgery. Payment rates are based on categories of services that are similar in cost and resource utilization.

Answer 21

Ambulatory Payment Classification (APC) System

Question 22

Upon admission to home health, the patient is assessed using the ___________________________. This is a prospective nursing assessment instrument that’s score, along with other data on the patient, determines the _________________ the patient will be placed in. The _____________ sets the reimbursement rate.

Answer 22

Outcome and Assessment Information Set (OASIS);
Home Health Resource Group (HHRG);
HHRG

Question 23

This case-mix classification model relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories. One case-mix variable is the assignment of the principal diagnosis to one of 12 clinical groups to explain the primary reason for home health services. Payment is based on this assignment

Answer 23

Patient-Driven Groupings Model (PDGM)

Question 24

This case-mix classification model is used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay.

Answer 24

Patient Driven Payment Model (PDPM)

Question 25

With _____ _________, the HMO and contracted provider each accept partial responsibility for the financial risk and rewards involved in cost-effectively caring for the members enrolled in the plan and assigned to the provider.

Answer 25

risk sharing

Question 26

With ___________, the provider or provider organization(s) take on more risk because they agree to receive a set payment per-member-per-month (PMPM) for specified medical services from the payer.

Answer 26

capitation

Question 27

The ______ __________ __ _________ ______ ________ assigns a number or alphanumeric to describe diseases, traumas, and environmental circumstances leading to bodily harm. It is used to report medical diagnoses and procedures on claims as well as to train data for public health surveillance. The ___ _____ is the diagnosis/reason for the encounter with the health system (e.g. chest pain, pre-op evaluation, diabetes).

Answer 27

International Classification of Diseases (ICD) coding system; ICD code

Question 28

(Clinical modification) The diagnosis classification system used by all healthcare providers.

Answer 28

ICD-10-CM

Question 29

(Procedure Coding System) The procedure classification system used for inpatient procedure reporting in hospitals.

Answer 29

ICD-10-PCS

Question 30

A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by health care providers and usually used for billing purposes (e.g. evaluation and management, venipuncture, ECG).

Answer 30

Current procedural terminology (CPT)

Question 31

While the ______ code tells the reason for the visit (e.g., chest pain), the ____ code lists the procedure performed (e.g. evaluation and management, venipuncture, ECG).

Answer 31

ICD-10; CPT

Question 32

____ combines _____ codes with patient demographics, discharge status, and the presence of complications or comorbidities to classify a hospital admission into a payment category, based on the assumption that similar diagnoses should have similar hospital resource use and length of stay patterns.

Answer 32

DRG; ICD-10

Question 33

A set of healthcare providers including primary care physicians, specialists, and hospitals that work together collaboratively and accept collective accountability of the cost and quality of care delivered to a population of patients. These became popular in the Medicare fee-for-service benefit system as a result of the Affordable Care Act and are formed around a variety of existing types of provider organizations such as multispecialty medical groups, physician-hospital organizations (PHI), and organized or integrated delivery systems. Core components of this model of care: 1. Provider-led - strong base in primary care 2. All providers, across a full continuum of care, are accountable for quality & cost r/t a population of patients 3. Payments are linked to quality improvements that reduce overall costs. 4. Performance is measured.

Answer 33

Accountable Care Organization (ACO)

Question 34

An approach to providing comprehensive, holistic and integrated primary care for children, youth, and adults. It is a care setting that facilitates partnerships among individual clients, client’s support systems and their primary care providers. Healthcare services in this setting are facilitated by disease registries, information technology, health information exchange and other means to assure that clients receive the necessary care when and where they need or desire it, in a culturally and linguistically appropriate manner. Some principles to remember: 1. Personal physician coordinates all care for the patient 2. Personal physician leads a team of providers who are collectively responsible for the ongoing care of the patient 3. Whole person orientation - personal physician provides for pt's entire healthcare needs or appropriately arranges care 4. Care is coordinated across all elements of the complex healthcare system and provided in a culturally and linguistically appropriate manner 5. enhanced access to care - open scheduling, expanded hours, new options for communication 6. Guided by evidence-based medicine and clinical decision-support tools 7. Physicians accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement 8. Patient participation in decision-making and feedback is sought to ensure expectations are met 9. IT is utilized appropriately to support optimal pt care, performance measurement, pt education, and communication

Answer 34

Patient Centered Medical Home (PCMH)

Question 35

______ ______ services are available to adults and children who receive benefits from Medicaid and who have at least 2 chronic conditions, such as asthma, diabetes, heart disease, obesity, a mental health condition, or substance abuse disorder; one chronic condition and are at risk for another; or one serious and persistent mental health condition. *Each patient must have a comprehensive care plan *Services must be quality-driven, cost-effective, culturally appropriate, person- and family-centered, and evidence-based *Services must include prevention and health promotion, healthcare, mental health and substance use, and long-term care services, as well as linkages to community supports and resources *Service delivery must involve continuing care strategies *Providers do not need to provide all the required services themselves but must ensure the full array of services is available and coordinated *Providers must use health information technology (HIT) to facilitate the work and establish quality improvement efforts

Answer 35

Health home

Question 36

A system of healthcare delivery that aims to provide a generalized structure and focus when managing the use, access, cost, quality, and effectiveness of healthcare services. Links the client to provider services. The two main types of _______ ____ organizations are Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs). Other types are exclusive provider organization (EPO) and point-of-service (POS) plans.

Answer 36

Managed Care

Question 37

A single organization or group of affiliated organizations that provides a wide spectrum of ambulatory and tertiary care and services. Care may also be provided across various settings of the healthcare continuum. This is a variety of providers and/or organizations that come together to provide a coordinated continuum of services to a defined population. The goal is to coordinate the seamless delivery of healthcare services.

Answer 37

Integrated Delivery System (IDS)

Question 38

A program in which contracts are established with providers of medical care. Providers under a _____ contract usually provide better benefits and deliver care at a discounted rate. Covered persons are generally allowed benefits for nonparticipating provider services, usually on an indemnity basis with significant copayments.

Answer 38

Preferred Provider Organization; PPO

Question 39

A managed care plan that provides benefits only if care is rendered by providers within a specific network. An ______ is similar to a PPO in that a network of providers have agreed to provide care for the members at a discounted rate. In an ____, however, a patient is not reimbursed for services if he chooses to receive healthcare outside the network.

Answer 39

Exclusive Provider Organization; EPO

Question 40

A type of managed care health insurance plan which combines characteristics of both the HMO and the PPO plans. Members of a ____ plan do not make a choice about which approach or plan to use until the point at which the service is needed and is being or about to be used. This plan also requires members to choose a PCP who in turn is responsible to make necessary referrals to SCPs or other healthcare services needed even if outside the plan’s network of providers. Members usually pay substantially higher costs in terms of increased premiums, deductibles and coinsurance. This plan allows the patient to choose to receive care in-network at little or no cost or to go out of network and incur larger out-of-pocket expenses.

Answer 40

Point-of-Service Plan; POS

Question 41

An organization that provides or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium - reimburses providers by capitation (a fixed amount per-member-per-month for contracted services). The primary care physician is often used as a "gatekeeper," meaning any care (other than emergency care) that is not coordinated through the PCP is not covered. There are four basic models of ______: group model, individual practice association (IPA), network model, and staff model. Under the Federal ____ Act, an organization must possess the following to call itself an _____: (1) an organized system for providing healthcare in a geographical area, (2) an agreed-on set of basic and supplemental health maintenance and treatment services, and (3) a voluntarily enrolled group of people.

Answer 41

Health Maintenance Organization (HMO)

Question 42

Services that are not included in the contract between the provider and the HMO can be "_______ ___" services. This means they are handled by other providers without penalty to the PCP. This is usually done for specialty services, such as transplant or mental behavioral health.

Answer 42

carve out

Question 43

The HMO contracts with a group of physicians for a set fee per client to provide many different health services in a central location. The group of physicians determines the compensation of each individual physician, often sharing profits. The physicians are employed by the group, not the HMO. The HMO and the group share profits or losses.

Answer 43

Group Model HMO

Question 44

The fastest growing form of managed care, this plan contracts with a variety of groups of physicians and other providers in a network of care with organized referral patterns. Networks allow providers to practice outside the HMO.

Answer 44

Network Model HMO

Question 45

A health maintenance organization (HMO) model of insurance that contracts with a private practice physician or healthcare association to provide healthcare services in return for a negotiated fee. The ____ then contracts with physicians who continue in their existing individual or group practice.

Answer 45

Individual Practice Association (IPA)

Question 46

The most rigid HMO model. Physicians are on the staff of the HMO with some sort of salaried arrangement and provide care exclusively for the health plan enrollees.

Answer 46

Staff Model HMO

Question 47

Management of health services to ensure that when offered they are medically necessary, provided in the most appropriate care setting, and at or above quality standards.

Answer 47

Utilization Management (UM)

Question 48

______________ ________, or precertifications, are done prior to the elective admission or procedure to ensure the requested service is necessary, meets criteria for coverage, and is at the appropriate level of care.

Answer 48

Prospective reviews

Question 49

A method of reviewing client care and services during a hospital stay to validate the necessity of care and to explore alternatives to inpatient care. It is also a form of utilization review that tracks the consumption of resources and the progress of clients while being treated.

Answer 49

Concurrent review

Question 50

A form of medical records review that is conducted after the client’s discharge to track appropriateness of care and consumption of resources.

Answer 50

Retrospective review

Question 51

According to Centers for Medicare & Medicaid Services (CMS), ____ ____ ____ ____ ________ LTAC- also referred to as ___ ____ ____ ______ (LTCH) and _______ ________ - focus on patients whose length of stay is greater than 25 days on average. Many of the patients in LTACs are transferred in from an intensive or critical care unit. LTACs specialize in treating patients who have one or more serious conditions but who may improve with time and care.

Answer 51

long-term acute care hospitals; long-term care hospitals; transitional hospitals

Question 52

Services provided in LTACs typically include: 1. 2. 3. 4.

Answer 52

1. comprehensive rehabilitation 2. respiratory therapy 3. head trauma treatment 4. pain management

Question 53

A healthcare facility that is a step down from an acute care hospital and a step up from a conventional skilled nursing facility intensity of services. _________ care is for patients who are stable and do not require hospital acute care, but who require more intensive skilled nursing care, therapy, and physician services than are provided to the majority of patients in a SNF. These services may include TPN, IV therapy, wound care, and other therapies such as speech therapy, physical therapy, occupational therapy, and respiratory therapy.

Answer 53

Subacute Care Facility; Subacute

Question 54

Inpatient rehabilitation hospitals provide intense, multidisciplinary therapy to patients with a functional loss. To qualify for this level of care, patients must be able to tolerate a minimum of ____ hours of therapy per day, ___ to ___ days per week and be ________ _______.

Answer 54

three hours per day; 5 to 7 days per week; medically stable

Question 55

______ _____ ________ offer 24-hour skilled nursing and personal care (e.g. bathing, eating, toileting). They also provide rehabilitation services, such as physical therapy, occupational therapy, and speech therapy. Patients must be medically stable to qualify for ___ level of care. They also must need care from a skilled, licensed professional, such as a nurse or therapist, on a daily basis. Examples are complex wound care and rehabilitation when a patient cannot tolerate 3 hours of therapy per day.

Answer 55

Skilled Nursing Facility; SNF

Question 56

A level of care for patients who require more assistance than custodial care and may require nursing supervision, but do not have a true skilled need. Most insurance companies do not cover this care.

Answer 56

Intermediate care

Question 57

Care provided primarily to assist a client in meeting the activities of daily living but not requiring skilled nursing care. Medical insurance does not cover this level of care.

Answer 57

Custodial care