Chapter 7 Flashcards
Outlier?
Case in which the cost of patient treatment is unusually and extremely high compared to other patients with similar conditions and treatment.
Scope of work?
Plan for targeting and implementing quality of care improvements.
Hill-Burton Act?
passed in 1946, provided hospitals with funding to construct new buildings or improve facilities to meet the expanding demand for medical care.
Allowed charges?
The maximum amount Medicare (or other third-party payer) will reimburse for services.
Medicare Shared Savings Program(MSSP)?
A CMS program that facilitates coordination and cooperation among providers to improve the quality of care provided to Medicare fee-for-service beneficiaries and to reduce unnecessary cost through participation in an ACO.
Case Mix Index?
The average relative weights of all of the MS-DRGs representative of the severity of all patients admitted to a facility.
Pioneer ACO Program?
An ACO model for hospitals and care providers who have experience with coordinating care for patients across the continuum of care (across different care settings).
Hospital Readmission Reduction Program (HRP)?
A program that requires CMS to reduce payments to hospitals with excessive readmission rates.
Hospital Quality Initiative?
A program developed by the Department of Health and Human Services, to “assure quality health care for all Americans through accountability and public disclosure.”
Hospital Value-Based Purchasing(VBP)?
A pay-for-performance methodology in which hospitals are rewarded for providing high-quality, cost-effective care and meeting performance measures for quality and efficiency.
Making all nursing assistants go through training on bedside manner is an example of risk__?
prevention
BlueCross/Blue Shield Insurance Company is considered a___?
covered entity.
Prior to 1966, elderly people__
didn’t have healthcare
Risk management has only been a recognized discipline since the 1970s because___?
hospitals were previously viewed as charitable organizations.
A risk manager is reviewing the health record doc. of Nurse David for an ongoing legal case. What piece of info would need to be reported as inappropriate?
“Nurse Smith look too long taking patient’s vitals.”
Info Government is what?
Determining who will be responsible for the release and tracking of patient data
HAC is what?
Ailments or injuries sustained by a patient during his or her hospital stay.
Spell of illness is what?
A Medicare definition of coverage based on the consecutive days a patient is receiving care
Pre-authorization is what?
Obtaining permission from an insurance company prior to treatments or procedures being performed.
RBRVS is what?
Medicare reimbursement system used to reimburse physicians.
Six Sigma is what?
Data-driven quality improvement process.
Utilization management is what?
The functions that ensure the appropriateness of admission, that ensure the medical necessity of planned hospital services, and that secure pre-authorization from third-party payers to perform services
Incident report is what?
Documentation of unusual or abnormal situations.
What is true of the reimbursement cycle?
The steps are done each time.
