Chapter 7

Question 1

Outlier?

Answer 1

Case in which the cost of patient treatment is unusually and extremely high compared to other patients with similar conditions and treatment.

Question 2

Scope of work?

Answer 2

Plan for targeting and implementing quality of care improvements.

Question 3

Hill-Burton Act?

Answer 3

passed in 1946, provided hospitals with funding to construct new buildings or improve facilities to meet the expanding demand for medical care.

Question 4

Allowed charges?

Answer 4

The maximum amount Medicare (or other third-party payer) will reimburse for services.

Question 5

Medicare Shared Savings Program(MSSP)?

Answer 5

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.

Question 6

Case Mix Index?

Answer 6

The average relative weights of all of the MS-DRGs representative of the severity of all patients admitted to a facility.

Question 7

Pioneer ACO Program?

Answer 7

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).

Question 8

Hospital Readmission Reduction Program (HRP)?

Answer 8

A program that requires CMS to reduce payments to hospitals with excessive readmission rates.

Question 9

Hospital Quality Initiative?

Answer 9

A program developed by the Department of Health and Human Services, to “assure quality health care for all Americans through accountability and public disclosure.”

Question 10

Hospital Value-Based Purchasing(VBP)?

Answer 10

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.

Question 11

Making all nursing assistants go through training on bedside manner is an example of risk__?

Answer 11

prevention

Question 12

BlueCross/Blue Shield Insurance Company is considered a___?

Answer 12

covered entity.

Question 13

Prior to 1966, elderly people__

Answer 13

didn’t have healthcare

Question 14

Risk management has only been a recognized discipline since the 1970s because___?

Answer 14

hospitals were previously viewed as charitable organizations.

Question 15

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?

Answer 15

“Nurse Smith look too long taking patient’s vitals.”

Question 16

Info Government is what?

Answer 16

Determining who will be responsible for the release and tracking of patient data

Question 17

HAC is what?

Answer 17

Ailments or injuries sustained by a patient during his or her hospital stay.

Question 18

Spell of illness is what?

Answer 18

A Medicare definition of coverage based on the consecutive days a patient is receiving care

Question 19

Pre-authorization is what?

Answer 19

Obtaining permission from an insurance company prior to treatments or procedures being performed.

Question 20

RBRVS is what?

Answer 20

Medicare reimbursement system used to reimburse physicians.

Question 21

Six Sigma is what?

Answer 21

Data-driven quality improvement process.

Question 22

Utilization management is what?

Answer 22

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

Question 23

Incident report is what?

Answer 23

Documentation of unusual or abnormal situations.

Question 24

What is true of the reimbursement cycle?

Answer 24

The steps are done each time.