Exam 2 Review

Question 0

public hospitals

Answer 0

oldest type of hospital

owned by federal, state, or local government

Question 1

American Medical Association (AMA)

Answer 1

protected the interests of providers

caused their rep to become more prestigious

Question 2

federal hospitals

Answer 2

don’t serve the general public, they serve beneficiaries like veterans, military members, and native americans

Question 3

voluntary hospitals

Answer 3

not government owned and non-profit

financed through community efforts

Question 4

proprietary hospitals

Answer 4

investor owned hospitals
for profit, owned by corporations, individuals, or partnerships
primary goal is to make money

Question 5

acute care hospitals

Answer 5

focuses on patients that stay 30 days or less

Question 6

Medicare Rural Hospital Flexibility Program (MRHFP)

Answer 6

created because rural hospitals see more poor and elderly, resulting in financial issues
it allows some rural hospitals to be classified as critical access hospitals if they have <25 acute care beds–they can get extra Medicare reimbursement

Question 7

chief of medical staff

Answer 7

in charge of the medical staff/physicians that provide clinical services to the hospital

Question 8

certification of hospitals

Answer 8

allows them to get Medicare and Medicaid reimbursement
mandated by DHHS
must adhere to conditions of participation

Question 9

accreditation of hospitals

Answer 9

private standard developed by accepted organizations to meet certain standards
-The Joint Commission accreditation means they met Medicare and Medicaid standards and don’t need certification

Question 10

Patient Self-Determination Act of 1990

Answer 10

requires hospitals that are in Medicare and Medicaid programs to provide patients with information on their rights upon admission
-Patient Bill of Rights

Question 11

3 cost containment approaches for facilities

Answer 11

1. Lean-staff identify patient care processes that are inefficient and revise them
2. Six Sigma-uses statistics to identify and eliminate defects in patient care
3. Plan Do Study Act-4 step cycle that focuses on improving workflow

Question 12

why were urgent/emergent care centers established?

Answer 12

for consumers that needed medical care but not life threatening. they take the place of the ER for those that really don’t need it

Question 13

Health Centers

Answer 13

provide culturally competent primary healthcare services to the uninsured or indigent population

Question 14

respite care

Answer 14

temporary care program, established to provide relief to the caregivers of chronically ill patients that needed a mental break

Question 15

hospice care

Answer 15

provides care for patients with life threatening illness and comfort for the patient’s family

Question 16

hospice care teams

Answer 16

work together to care for chronically ill patients

nurses, doctors, social workers, therapists, clergy, etc

Question 17

why is primary care the essential component of the us healthcare system?

Answer 17

it is often the point of entry of most people since it focuses on preventative and routine care

Question 18

secondary care

Answer 18

focuses on short term interventions that may require a specialist’s intervention
-hospitalization, routine surgery, specialty consultation

Question 19

difference between a doctor of medicine and a doctor of osteopathic medicine

Answer 19

a doctor of osteopathic medicine uses more holistic approach focusing on the entire person, and a doctor of medicine uses an allopathic approach

Question 20

allopathic approach

Answer 20

actively intervening in attacking and eradicating the disease

Question 21

hospitalist

Answer 21

physician that provides care to hospitalized patients, usually a general practitioner and can provide more efficient care. they monitor the patient from admittance to discharge

Question 22

nonphysician practitioner (NPP)

Answer 22

general term including physician assistants, nurse practitioners, and certified nurse practitioners

Question 23

physician extenders

Answer 23

NPP are often called this because they are often used as a substitute for physicians but not involved in total care

Question 24

physician assistants (PA)

Answer 24

category of NPP, provide range of diagnostic and therapeutic services, can prescribe medicines in all but 3 states, and must be supervised by a physician but can be indirect

Question 25

how are nurses represented in the workforce

Answer 25

largest group of healthcare professionals and provide majority of care, they are the advocates though there is always a shortage

Question 26

certified nursing assistants (CNA)

Answer 26

unlicensed attendants that work under supervision of physicians and nurses
-answer call bells, help patients with personal hygiene, ordering meals, changing beds

Question 27

dentists

Answer 27

pregvent, diagnose, and treat teeth, gum, and mouth disease
-bachelors degree then 4 years of dental school with DDS or DDM degree, and 2-4 years after for a specialty such as orthodontics

Question 28

sonographer

Answer 28

provides patient services using medical ultrasound, which photographs internal structures

Question 29

exercise physiologists

Answer 29

assess, design, and manage individual exercise programs for both healthy and unhealthy individuals

Question 30

prosthetist

Answer 30

designs “prostheses” or devices for patients who have limb amputations to replace the limb

Question 31

perfusionist

Answer 31

operates equipment to support or replace a patient’s circulatory or respiratory function
-responsible for administering blood byproducts or anesthetic products during surgical procedure

Question 32

recreational therapists

Answer 32

provide individualized and group recreational therapy for individuals experiencing limitations in lift activities as a result of a disabling condition, illness or disease, aging, and/or developmental factors

Question 33

transfusion medicine specialists

Answer 33

specialists in blood bank technology (SSB)

provide routine and specialized tests for blood donor centers, transfusion centers, labs, and research centers

Question 34

general tasks of pharmacy technicians

Answer 34

1. take info needed to fill prescriptions
2. count pills and measure other meds
3. compound or mix medications
4. pack and label meds
5. process insurance claims
6. do routine tasks

Question 35

health services administrators

Answer 35

responsible for strategic planning and overall success of organization

• responsible for financial, clinical, and operational outcomes of an organization
• focus on efficiency and effectiveness at all levels

Question 36

why was health insurance developed?

Answer 36

provide protection should a covered individual experience an event

Question 37

copayments

Answer 37

costs that patients must pay at the point of service, and is designated

Question 38

coinsurance

Answer 38

type of copayment that is part of a fee-for-service policy

-patient pays a % of the total cost of service, typically 20%

Question 39

deductible

Answer 39

payments that must be met prior to insurance paying for services
-ex) if deductible is $250, the consumer must pay up to $250 before the insurance begins to cover services

Question 40

flexible spending accounts (FSA)

Answer 40

allow employees to set aside pretax income to pay for out-of-pocket expenses
-must submit claims for the expenses and are reimbursed, but must be spent within 1 year

Question 41

Medicare Part B

Answer 41

supplemental health plan to cover 2 types: medically necessary services and preventive services
-financed 24% from enrollee payments

Question 42

Community First Choice

Answer 42

optional Medicaid benefit from ACA, that allows consumers to receive care at home or community health centers rather than a hospital or facility

Question 43

balance billing

Answer 43

would allow the physician to bill the patient the difference between Medicare payments and their own charges, even if they accepted Medicare reimbursement as full payment

Question 44

resource utilization groups

Answer 44

type of diagnostic related group designed to differentiate patients based on how much they use the resources of the facility

Question 45

Home Health Resource Group

Answer 45

prospective payment used by Medicare that pays a fixed predetermined amount for each 60-day episode of care

Question 46

Bundled payments initiative

Answer 46

4 models of care that link payments that multiple service beneficiaries receive during an episode of care

Question 47

retrospective bundled payment

Answer 47

models 2 and 3 of a bundled payment initiative

-actual expenditures are reconciled against a target price for an episode of care

Question 48

accountable care organizations (ACO)

Answer 48

groups of providers and hospitals that volunteer to give coordinated care to Medicare patients
-goal: ensure patients receive timely care while avoiding duplication of services and errors

Question 49

auditing

Answer 49

ensuring accounting procedures are performed in accordance with regulations

Question 50

claims processing

Answer 50

disbursement of funds

-most insurance companies and MCOs have a claims department to handle these

Question 51

managed care

Answer 51

cost management of healthcare services by controlling who consumer sees and how much service costs

Question 52

health maintenance organizations (HMO)

Answer 52

oldest type of managed care

• must see PCP first in order to see a specialist
• there are 4 types

Question 53

independent practice associations (IPA)

Answer 53

type of health maintenance organization

-contract with a group of physicians who are in private practice to see MCO members at a prepaid rate per visit

Question 54

preferred provider organizations (PPO)

Answer 54

providers agree to value-based fee schedule or a discounted fee

• no gatekeeper=no referrals needed
• no copay but there is a deductible

Question 55

physician hospital organizations (PHO)

Answer 55

physician hospitals, surgical centers, and other medical providers that contract with managed care plan to provide services

Question 56

point of service plans (POS)

Answer 56

blend of HMO and PPO

• encourage but don’t require PCP, but there is a lower fee if they do
• can see out of network provider but will be charged more

Question 57

capitation policy

Answer 57

“per member per month (PMPM) policy”

provider is paid a fixed monthly amount per member regardless of how often the members use the service

Question 58

prospective utilization review

Answer 58

implemented before the service is performed by having the procedure authorized by the MCO, having the PCP refer member for service, or assessing service based on guidelines

Question 59

carve-outs

Answer 59

services that Medicaid is not obligated to pay for under MCO contract
-mental health services and substance abuse treatment often fall under this category

Question 60

Accreditation Association for Ambulatory Health Care (AAAHC)

Answer 60

reviews and accredits MCOs, and can survey Medicare Advantage HMOs and PPOs