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CCMC > Domain 1 > Flashcards

Domain 1 Flashcards

1
Q

Triple Aim

A
  1. Improve experience of care
  2. Improve health of populations
  3. Reduce per capita cost of care
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2
Q

Managed Care – Healthcare Delivery System

A

Organizations that provide healthcare to members using contacted providers

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3
Q

Diagnosis Related Group (DRG) System – Coding Methodology

A

Pays fixed amount for given diagnosis instead of paying all costs related to treatment, Medicare uses

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4
Q

Preferred Provider Organization (PPO) – Managed Care Concept

A

Contract providers to deliver care at discounted rate, and cover minimal cost for providers not contracted

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5
Q

Exclusive Provider Organization (EPO) – Managed Care Concept

A

Contract providers to deliver care at discounted rate but do not cover any cost for providers not contracted

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6
Q

Point of Service (POS) – Managed Care Concept

A

Choose to receive care in network at little to no cost or go out of network and incur larger out of pocket cost

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7
Q

Health Maintenance Organization (HMO) – Managed Care Concept

A

Pay providers with a fixed amount per member per month, primary care physician is gatekeeper

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8
Q

Acute Care – Level of Care

A

Most intensive, brief but severe illness, typically provided in hospital

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9
Q

Long-Term Acute Care Hospital – Level of Care

A

Length of stay greater than 25 days, 1+ serious conditions who may improve with time and care

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10
Q

Subacute Care – Level of Care

A

Stable, does not require hospital acute care, requires more intensive skilled care/therapy than a regular facility

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11
Q

Inpatient Rehabilitation – Level of Care

A

Intense, multidisciplinary therapy to patients with functional loss

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12
Q

Skilled Nursing Facility (SNF) – Level of Care

A

24 hour skilled nursing and personal care, rehab if needed, must be medically stable and require licensed professional

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13
Q

Intermediate Care – Level of Care

A

Require more assistance than custodial care

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14
Q

Home Health Care – Level of Care

A

Under Medicare they must be homebound, nursing/therapy to patients in their home

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15
Q

Hospice Care – Level of Care

A

End of life care (6 months or less) for those with terminal illness, provided in any setting, palliative care, bereavement support for family

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16
Q

Custodial Care – Level of Care

A

Assists with ADLs and IADLs and medical needs, no licensed worker needed

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17
Q

Assisted Living – Level of Care

A

Housing and support with ADLs and IADLs, no medical care provided

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18
Q

Medicaid Health Home – Model of Care

A

Multiple chronic conditions, caring for the whole person (primary and behavioral healthcare), children and adults

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19
Q

Patient Centered Medical Home (PCMH) – Model of Care

A

Treatment coordinated through primary care, whole person care

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20
Q

Current Procedural Terminology (CPT) – Coding Methodology

A

Used to report services performed to payers for reimbursement purposes, lists procedures performed

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21
Q

International Classification of Diseases (ICD-10) – Coding Methodology

A

Used to report medical diagnoses and procedures on claims and to gain data for public health surveillance, diagnosis/reason for encounter with health system

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22
Q

Fee for Service – Reimbursement and Payment Methodology

A

Each service rendered is priced separately

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23
Q

Bundled Rate – Reimbursement and Payment Methodology

A

Bundling charges to multiple providers in multiple settings

24
Q

Case Rate – Reimbursement and Payment Methodology

A

Flat fee paid to provider for treatment based on diagnoses

25
Q

Prospective Payment System – Reimbursement and Payment Methodology

A

Payment is made based on predetermined, fixed amount

26
Q

Supplemental Security Income (SSI)

A

Cash assistance for the disabled with limited income and resources

27
Q

Social Security Disability Insurance (SSDI)

A

Payment for those who are unable to perform the work they previously did and not able to adjust to other work because of their condition (1 year or longer)

28
Q

Medicaid

A

Poor

29
Q

Medicare (Part A-D)

A

Old and disabled
A- hospital insurance
B- medical insurance
C- Medicare Advantage Plan
D- prescriptions

30
Q

1986 Consolidated Omnibus Budget Reconciliation Act (COBRA)

A

Federal law that allows employees and their families who might otherwise lose their insurance due to certain events to choose to keep it
-Employee death
-Employee job loss/hour reduction
-Employee entitled to Medicare
-Employee divorce/separation
-Child loses dependent status

31
Q

Indeminity

A

Benefits in the form of payments instead of services (reimbursement of cost)

32
Q

Short-Term and Long-Term Disability

A

Payments for non-work related injury paid by employer and/or employee

33
Q

Birthday Rule – Coordination of Benefits

A

If parents are married, parent with birthday first’s insurance is primary for children

34
Q

Accelerated Dealth Benefit

A

Insured person with terminal illness can use some of the policy’s benefit prior to dying (deducted after death), no restrictions

35
Q

Viatical Settlements

A

Sells life insurance policy of person with terminal/life-threatening illness with life expectancy of less than 5 years to a third party for cash, no restrictions, paid 50-80% of face value

36
Q

Reverse Mortage

A

62+, borrows against home’s value without leaving or making payments, no restrictions, repaid after death/selling/moving

37
Q

Palliative Care

A

Maintain best quality of life through symptom management

38
Q

Patient Self-Determination Act

A

Federal law requiring agencies receiving Medicare and Medicaid reimbursement to recognize living will and POA

39
Q

Case Management Process (steps in order)

A
  1. Screening
  2. Stratifying Risk
  3. Assessment
  4. Planning
  5. Implementing
  6. Follow up/Monitoring
  7. Transitioning/Transitional Care
  8. Post-transition Communication
  9. Evaluation
40
Q

SMART (acronym)

A

Used to identify attributes of effective goals
S- Specific
M- Measureable
A- Achievable
R- Realistic
T- Time-bound

41
Q

Adherence

A

Carrying out the treatment plan correctly

42
Q

Interdisciplinary/Interprofessional Care Team

A

Group of healthcare professionals from various disciplines that work together to manage all needs of patient

43
Q

Critical Access Hospital (CAH) – Level of Care

A

Small hospitals in rural areas

44
Q

Short-Term Acute Care Hospital – Level of Care

A

Provide diagnostic and therapeutic services for 4-5 days

45
Q

Capitation

A

Fixed amount paid per month per member to provider for covered costs

46
Q

Risk Sharing

A

HMO and provider share responsibility for financial risk/reward involved in cost-effectively caring

47
Q

Indeminity

A

Security against possible loss or damages

48
Q

Stop Loss

A

Payment may increase after specific dollar threshold is met

49
Q

Third Party Administrators (TPA)

A

Organization outside of insuring organization that handles only adminstrative functions

50
Q

Value Based Purchasing (VBP)

A

Payment based on outcomes of specific diseases

51
Q

Hierarchical Condition Category (HCC) – Coding Methodology

A

Estimates future health care costs for clients

52
Q

Resource Utilization Groups (RUGS) – Coding Methodology

A

Pays for nursing facility care based on amount, intensity, and type

53
Q

Home Health Resource Groups – Coding Methodology

A

Pays home health agencies for services based on resources used and duration

54
Q

1974 Employee Retirement Income Security Act (ERISA)

A

Minimum standards for voluntary retirement and health plans in the private industry

55
Q

Disease Management

A

Focus on health promotion and prevention strategies

56
Q

2010 Patient Protection and Affordable Care Act (ACA)

A

Act that created health insurance reforms designed to increase access, lower cost, improve quality, add new consumer protections (end pre-existing condition discrimination, end arbirary withdrawals of insurance coverage, keep young adults covered, free preventative care benefits, cover mental health, end dollar limits, pay physicians on value), and increase skill and proficiency of case managers

57
Q

HUDDLE (acronym)

A

Stategy to improve communication and facilitate better outcomes
H- Health care
U- Utilizing
D- Deliberate
D- Discussion
L- Link
E- Events

CCMC (5 decks)

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