Final (7-11) Flashcards
Six Sigma
A data driven method for improving processes (for achieving quality) that involves the five-step process • Define • Measure • Analyze • improve
Incident Report
Incident Report
• Data collected about any abnormal occurrence involving a patient, a visitor, or an employee that detail the circumstances surrounding the incident and are used in the facility’s internal investigation
• It is never filed as a part of the patients record
Pre-Authorization
The requirement of some managed care plans that patients seek authorization (approval) for testing or admission in order for the insurance to pay for the services (providing that other requirements, such as, medical necessity, are met)
Hospital Acquired Condition
Diagnoses that appeared after a patient was admitted but which perhaps should not have occurred-for instance, a urinary tract infection in a patient who was catheterized while hospitalized or a fall that resulted in a fracture
Resource-based relative value scale - RBRVS
The reimbursement method used by Medicare and Medicaid to reimburse physicians according to a fee schedule that is based on weights assigned to resources used to provide the services, including the cost of work performed, the expenses incurred to operate a medical practice, and the cost of malpractice insurance, and that is adjusted based on the geographic region where the practice is located.
Tricare
Healthcare coverage for active armed services personnel, dependents, and retirees who receive care outside military treatment facilities; the federal government pays a portion of the healthcare costs
Managed Care
Includes:
• Health Maitenece Organization (HMOs)
• Preferred provider organizations (PPOs)
• Exclusive provider organizations (EPOs)
• Point of Service Plans (POS)
Benefits include:
• Coordinated care through a primary care physician (gatekeeper)
• Focus on preventative care
• Use of disease management tools (evidence-based or clinical practice guidelines
• Case management
• Cost controls
Negative Aspects include:
• Time spent and work involved in seeking pre-approval of services
• Requirement to see in-network providers
• Physicians feeling that they are told how to treat their patients and cannot make decisions without approval of managed care plan
• Fear that quality will be sacrificed to save money
Hill Burton Act (1946)
Provided hospitals with funding to construct new buildings or improve facilities to meet the expanding demand for medical care
Prospective Payment System
Considered a system of averages—a hospital will make money on some patients but will lose money on some, however, in the end, a hospital should at least break even.
Lifetime Reserve Days
A one-time bank of a maximum of 60 days of inpatient service days after the use of the first 90 benefit days per spell of illness. Lifetime reserve days can be split among more than one inpatient hospitalization
Hospital Readmission Reduction Program
Part of the affordable care act - a program that requires CMS to reduce payments to hospitals with excessive readmission rates
Pioneer ACO Program
An ACO (Accountable Care Organization) Model for hospitals and care providers who have experience with coordinating care for patients across the continuum of care (across different care settings)
Direct Messaging
A health information network initiative used by providers to easily and securely send patient information – such as laboratory orders and results, patient referrals, or discharge summaries-directly to another healthcare professional. This information is sent over the internet in an encrypted secure and reliable way among health-care professionals who already know and trust each other, and is commonly compared to sending secured email.
5 Elements of Interoperability
- Adoptions and optimization of HER and HIE services
- Standards to support implementation and certification
- Financial and clinical incentives
- Privacy and security
- Rules of engagement or governance
Business Associate- Examples
Third-party administrator that assists a health plan with claims processing
Consultant that performs utilization reviews for a hospital
Health care clearinghouse that translates a claim from a nonstandard format into a standard transaction on behalf of a health care provider, and forwards the processed transaction to a payer
Independent medical transcriptionist that provides transcription services to a physician