Effective Resource Management Flashcards
When discussing ongoing healthcare system changes, an example of Legislative and regulatory reforms would be:
A. Health Insurance Portability and Accountability Act (HIPAA)
B. Patient Protection and Affordable Care Act (PPACA)
C. Healthcare and Education Reconciliation Act (HCERA)
D. All of the Above
D. All of the above
Which of the following would be considered drivers of excess cost in healthcare?
A. Unnecessary services
B. Excess Administrative Costs
C. Missed Prevention Opportunities
D. All of the above
D. All of the above
CMS suggests that US healthcare spending will ____ and the government will foot the bill for 47% of healthcare spending by 2027.
A. Decrease
B. Remain flat
C. Increase
D. None of the above
C. Increase
What is a CMS condition code 44?
A. Patient has an outpatient only procedure in an inpatient bed.
B. An inpatient admission is changed to outpatient.
C. This does not exist
D. Condition that is determined by the physician only.
B. An inpatient admission is changed to outpatient.
Utilization Review is what?
A. a process of reviewing patient records to assess completion and accuracy after the treatment has occurred.
B. the prospective and retrospective examination of the diagnosis, treatment and outcomes of patient care.
C. a process of auditing charts for quality measures
D. none of the above.
A. a process of reviewing patient records to assess completion and accuracy after the treatment has occurred.
Utilization management is what?
A. a process of reviewing patient records to assess completion and accuracy after the treatment has occurred.
B. the prospective and retrospective examination of the diagnosis, treatment and outcomes of patient care.
C. a process of auditing charts for quality measures
D. none of the above.
B. The prospective and retrospective examination of the diagnosis, treatment and outcomes of patient care.
What are the reviews prior to services being rendered?
A. Pre-admission reviews
B. Pre-Certification reviews
C. Cost-Containment reviews
D. Both A and B.
D. Both A and B.
What is the name of a review or authorization for procedures or services at the time the services are being rendered?
A. Retrospective
B. Prospective
C. Concurrent
D. Utilization
C. Concurrent
What is the name of the organization that is dedicated to improving healthcare quality?
A. NCQA (National Committee for Quality Assurance)
B. URAC (Utilitaztion Review Accrediation Commission)
C. MCO (Managed Care Orginization)
D. None of the above
A. NCQA (National Committee for Quality Assurance)
Clinical criteria to be met for specific procedures, length of stay recommendations and criteria for continued stay and discharge planning are considered what?
A. Conditions of participation
B. Medical Necessity Criteria
C. Industry standards
D. Managed care criteria
B. Medical Necessity Criteria
Comprehensive case management services that address the client’s total situation bringing the social, mental, emotional and economic domains of care and resources to the center of the process.
Wholistic Case Management
A portion of payments held by the MCO until year end and not returned to the provider unless specific target utilization rates are achieved, often used by HMOs to control utilization of referrals.
withhold
Models where healthcare resources, services and case managers are based within the acute care/hospital setting.
Within-the-walls case management
Use of real or simulated work activity under close supervision at a rehabilitation facility or other work setting to develop appropriate work behaviors, attitudes or personal characteristics.
work adjustment
Goal-directed services for persons whose disabilities limit them from obtaining competitive employement focused on improving problem areas such as attendance, hygiene, interpersonal relationships, etc.
work adjustment training
