Domain 1

Question 1

Triple Aim

Answer 1

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

Question 2

Managed Care – Healthcare Delivery System

Answer 2

Organizations that provide healthcare to members using contacted providers

Question 3

Diagnosis Related Group (DRG) System – Coding Methodology

Answer 3

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

Question 4

Preferred Provider Organization (PPO) – Managed Care Concept

Answer 4

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

Question 5

Exclusive Provider Organization (EPO) – Managed Care Concept

Answer 5

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

Question 6

Point of Service (POS) – Managed Care Concept

Answer 6

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

Question 7

Health Maintenance Organization (HMO) – Managed Care Concept

Answer 7

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

Question 8

Acute Care – Level of Care

Answer 8

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

Question 9

Long-Term Acute Care Hospital – Level of Care

Answer 9

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

Question 10

Subacute Care – Level of Care

Answer 10

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

Question 11

Inpatient Rehabilitation – Level of Care

Answer 11

Intense, multidisciplinary therapy to patients with functional loss

Question 12

Skilled Nursing Facility (SNF) – Level of Care

Answer 12

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

Question 13

Intermediate Care – Level of Care

Answer 13

Require more assistance than custodial care

Question 14

Home Health Care – Level of Care

Answer 14

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

Question 15

Hospice Care – Level of Care

Answer 15

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

Question 16

Custodial Care – Level of Care

Answer 16

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

Question 17

Assisted Living – Level of Care

Answer 17

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

Question 18

Medicaid Health Home – Model of Care

Answer 18

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

Question 19

Patient Centered Medical Home (PCMH) – Model of Care

Answer 19

Treatment coordinated through primary care, whole person care

Question 20

Current Procedural Terminology (CPT) – Coding Methodology

Answer 20

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

Question 21

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

Answer 21

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

Question 22

Fee for Service – Reimbursement and Payment Methodology

Answer 22

Each service rendered is priced separately

Question 23

Bundled Rate – Reimbursement and Payment Methodology

Answer 23

Bundling charges to multiple providers in multiple settings

Question 24

Case Rate – Reimbursement and Payment Methodology

Answer 24

Flat fee paid to provider for treatment based on diagnoses

Question 25

Prospective Payment System -- Reimbursement and Payment Methodology

Answer 25

Payment is made based on predetermined, fixed amount

Question 26

Supplemental Security Income (SSI)

Answer 26

Cash assistance for the disabled with limited income and resources

Question 27

Social Security Disability Insurance (SSDI)

Answer 27

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)

Question 28

Medicaid

Answer 28

Poor

Question 29

Medicare (Part A-D)

Answer 29

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

Question 30

1986 Consolidated Omnibus Budget Reconciliation Act (COBRA)

Answer 30

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

Question 31

Indeminity

Answer 31

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

Question 32

Short-Term and Long-Term Disability

Answer 32

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

Question 33

Birthday Rule -- Coordination of Benefits

Answer 33

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

Question 34

Accelerated Dealth Benefit

Answer 34

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

Question 35

Viatical Settlements

Answer 35

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

Question 36

Reverse Mortage

Answer 36

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

Question 37

Palliative Care

Answer 37

Maintain best quality of life through symptom management

Question 38

Patient Self-Determination Act

Answer 38

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

Question 39

Case Management Process (steps in order)

Answer 39

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

Question 40

SMART (acronym)

Answer 40

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

Question 41

Adherence

Answer 41

Carrying out the treatment plan correctly

Question 42

Interdisciplinary/Interprofessional Care Team

Answer 42

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

Question 43

Critical Access Hospital (CAH) -- Level of Care

Answer 43

Small hospitals in rural areas

Question 44

Short-Term Acute Care Hospital -- Level of Care

Answer 44

Provide diagnostic and therapeutic services for 4-5 days

Question 45

Capitation

Answer 45

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

Question 46

Risk Sharing

Answer 46

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

Question 47

Indeminity

Answer 47

Security against possible loss or damages

Question 48

Stop Loss

Answer 48

Payment may increase after specific dollar threshold is met

Question 49

Third Party Administrators (TPA)

Answer 49

Organization outside of insuring organization that handles only adminstrative functions

Question 50

Value Based Purchasing (VBP)

Answer 50

Payment based on outcomes of specific diseases

Question 51

Hierarchical Condition Category (HCC) -- Coding Methodology

Answer 51

Estimates future health care costs for clients

Question 52

Resource Utilization Groups (RUGS) -- Coding Methodology

Answer 52

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

Question 53

Home Health Resource Groups -- Coding Methodology

Answer 53

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

Question 54

1974 Employee Retirement Income Security Act (ERISA)

Answer 54

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

Question 55

Disease Management

Answer 55

Focus on health promotion and prevention strategies

Question 56

2010 Patient Protection and Affordable Care Act (ACA)

Answer 56

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

Question 57

HUDDLE (acronym)

Answer 57

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