Domain 1 - Care Delivery and Reimbursement Methods (Part 2)

Question 1

What is the main purpose of Accountable Care Organizations (ACO)?

Answer 1

Main purpose is to improve beneficiary outcomes and increase value of care by providing better care for individuals, better health for populations,
and reducing growth in expenditures (Triple Aim)

Question 2

What is the purpose of a Medicare Shared Savings Program?

Answer 2

Improve beneficiary outcomes and increase the value of care by providing:

• Better care for individuals
• Better health for populations
• Lower expenditures

Question 3

What is the purpose of Expansion of Federally Qualified Health Centers (FQHC)?

Answer 3

Their main purpose is to provide primary care services in underserved and rural areas.

Question 4

What is the meaning of Level of Care?

Answer 4

The level of care is the intensity of resources and services necessary to diagnose, treat, preserve, or maintain an individual’s physical and/or emotional health and functioning.

*The complexity and intensity of case management services are impacted by the context (level) of care setting, client’s health condition and needs, reimbursement method (managed care, capitation, bundled, etc.), type of
care provider, and intensity of resources and services required to meet the needs.
* Levels will vary across the continuum, moving from the least to the most complex (from prevention and wellness, to nonacute, rehabilitation, subacute, and to acute and up to critical) depending on the resources and services necessary at any moment in time
* The levels include prevention and wellness, nonacute, rehabilitation, subacute, acute, and critical

Question 5

Finish the sentence: Levels will vary across the continuum, moving from…

And what are the levels?

Answer 5

The least to the most
complex (from prevention and wellness, to nonacute, rehabilitation, subacute,
and to acute and up to critical) depending on the resources and services necessary at any moment in time.

The levels include prevention and wellness, nonacute, rehabilitation, subacute,
acute, and critical.

Question 6

Palliative care aims to:

Answer 6

Relieve suffering and improve quality of life for individuals
with advanced illness and is offered simultaneously with other appropriate medical treatment

Question 7

Types of insurance:

Answer 7

• Health
• Automobile
• Life
• Disability
• Homeowners/Renters
• Long-term care

Question 8

Utilization management

Answer 8

Management of health services to ensure appropriate care setting, and at or above quality standards.

Question 9

Utilization review

Answer 9

A mechanism used by some
insurers and employers to evaluate healthcare services on the basis of appropriateness, necessity, and quality.

Question 10

VBP

Answer 10

Value Based Purchasing

Organizations and providers can either receive
incentives or penalties for meeting or not meeting quality metrics
* Example – Quality domains are safety, clinical care, efficiency and cost reduction, and client and caregiver-centered experience of care/care coordination

Question 11

Population health management

Answer 11

A model of care that strives to address patients’ health needs at all points along the continuum of care, including the community setting, by increasing patient participation and engagement
and targeting interventions. The goal is to maintain or improve physical and psychosocial well-being and address health disparities through cost effective, tailored health solutions.

Question 12

Employee Retirement Income Security Act (ERISA)

Answer 12

ERISA sets uniform minimum standards to ensure that employee benefit plans are established or maintained in a fair and financially sound manner. In addition, employers have an obligation to provide promised benefits and satisfy ERISA’s requirements for managing and administering private retirement and welfare plans.
* Applies to voluntary health plans (benefit plans) in private industry, specifically for self-insured employer groups

Question 13

Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)

Answer 13

Requires certain employers to allow qualified employees, spouses, and dependents to continue health insurance coverage when it would otherwise stop (upon leaving employment, death of employee)

Question 14

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Answer 14

• Came about with electronic records and transfer of information
• Protects individual health records and personal health information (PHI)
• Limits release of information to minimum reasonable needed for the disclosure
• Also includes regulations for fraud and abuse
• Gives individuals rights to their own health records

Question 15

Liability insurance

Answer 15

benefits paid for bodily injury, property damage, or both

Question 16

Workers’ compensation

Answer 16

Plan that provides medical benefits and lost wages for
persons who have an illness or injury caused by or occurring because of work. Focus
on return to work. Heavy use of case management.

Question 17

Accident and health insurance

Answer 17

Includes payment for health-related costs. May have maximum limitations and may include long- or short-term disability for salary
replacement

Question 18

Indemnity

Answer 18

Security against possible loss or damages. Covered loss reimbursement paid in predetermined amount. In health insurance, these plans are also known as “fee for service” plans. Gives greatest amount of flexibility and freedom. Can be more costly

Question 19

Medicare

Answer 19

Intended to finance medical care for persons age 65 and older or the disabled who are entitled to social security benefits

Question 20

Medicare Part A covers:

Answer 20

Part A covers hospital, skilled nursing care, nursing home (with skilled need), hospice, home health care

Question 21

Medicare Part B covers:

Answer 21

Part B covers physician, outpatient, ambulance, clinical research, and mental health services

Question 22

Medicare Part D covers:

Answer 22

Part D covers prescription drugs

Question 23

Medicare Advantage

Answer 23

• Created by the Balanced Budget Act of 1997
• Option for Medicare enrollees
• Provided by private insurance plans
• Provides many services normally received under traditional Medicare with
  additional benefits
• Managed care plans, networks are based on plan contracts and may be narrow

Question 24

Secondary Medicare Insurance

Answer 24

• For Medicare beneficiaries who do not participate in Medicare Advantage Plan
• Covers co-pays and other financial responsibilities not covered by traditional Medicare

Question 25

Medicaid

Answer 25

• Finances health care of indigent and other special designated groups
  Proprietary and Confidential. May not be reproduced or redistributed.
• Financed jointly by federal and state governments
• Eligibility criteria vary from state to state
• Based on income, assets, and dependents

Question 26

Managed Medicaid

Answer 26

• Like Managed Medicare for Medicaid recipients
• Focus on cost containment, improved access, and quality of care
• Provides many healthcare services a Medicaid recipient would normally receive on a prepaid capitated basis
• May have narrow networks

Question 27

Is Worker’s Compensation federally mandated or state mandated?

Answer 27

State mandated

Question 28

Uncompensated care and the two categories

Answer 28

Occurs when a client/support system receives care, does not pay for the services, and the provider does not receive reimbursement. Uncompensated
care falls into two categories: charity care and bad debt

Question 29

Uncompensated care: charity care

Answer 29

Free full or partial care provided to clients who cannot afford to
pay for needed healthcare services.

Question 30

Uncompensated care: bad debt

Answer 30

Results from clients unwilling to pay for services, which can include co-payments, deductibles, or all charges. It also includes clients who cannot
pay for healthcare services and do not apply for financial assistance

Question 31

Short Term Care Hospital (STCH) (ACUTE)

Answer 31

• defined by the Social Security Act as an organization that is primarily engaged in providing diagnostic and therapeutic services for medical diagnosis, treatment, and care of the injured, disable or sick persons, or rehabilitation services for the same population
• This includes the general community hospital, academic medical center, children’s hospitals, cancer hospitals,
  behavioral/psychiatric hospitals
• Average length of stay 4-5 days

Question 32

Long Term Care Hospital (LTCH) (ACUTE)

Answer 32

• Certified by Medicare as an acute hospital
• Treat medically complex patients that require long-stay hospital level care
• Focus on patients who, on average, stay more than 25 days
• Specialize in the care of patients with more than one serious condition and who may improve over a longer period with intensive care and services, ultimately returning home

Question 33

Critical Access Hospital (CAH) (ACUTE)

Answer 33

• Designed to reduce financial vulnerability of rural hospitals and improve access to care by keeping essential services in rural
  communities
• They are at least 35 miles from any other hospital
• Have no more than 25 beds
• Average length of stay is 96 hours for acute care
• Provide 24 hour, 7-day emergency care
• Focus on providing care for common conditions and outpatient care,
  accessing large hospitals for more complex treatment

Question 34

Inpatient (Acute) Rehabilitation (ACUTE)

Answer 34

• Acute level of care – designated as an acute hospital by Medicare
• Can be provided in a stand-alone facility or as a distinct part within an
  acute care hospital
• Provides coordinated, intensive rehabilitation services
• Admitted person must be able to tolerate 3 hours of combined
  rehabilitation services a day
• 60% of admitted patients required to fall into one of 13 categories:
• Stroke
• Spinal cord injury
• Congenital deformity
• Amputation
• Major multiple trauma
• Fracture of the femur (hip)
• Brain injury
• Neurological disorders (Multiple Sclerosis, Muscular
  Dystrophy, Parkinson’s)
• Burns

Question 35

Skilled Nursing Facility (SUB-ACUTE)

Answer 35

• licensed healthcare residences for individuals who require a higher level of medical care than can be provided in an assisted living facility
• provide 24-hour, 7 day a week skilled nursing care
• services that can only be provided under the supervision of skilled and licensed healthcare personnel who are required to manage, observe, and evaluate the skilled care activities
• commonly used for short-term rehabilitative stays
• Expectation is that the individual will be able to return to the community

Question 36

Subacute care

Answer 36

• Subacute care is a level of care needed by a client who does not require hospital acute care, but who requires more intensive skilled nursing care than is provided to most clients in a skilled nursing facility – criteria is 4.5 to 8.0 direct nursing care hours daily
• Can be for short-term physical rehabilitation, complex medical
  services (including wound care or intravenous therapy), or long-term chronic care (medically stable but with a relatively high need for nursing or other ancillary services)
• Less intensive than acute rehabilitation
• Generally, clients in a subacute facility only receive between one and two hours of therapy per day.
• The average length of stay at a subacute facility is also generally longer than at an acute hospital

Question 37

Long Term Care (Custodial care)

Answer 37

• A range of services and support, given safely by unskilled, unlicensed personnel who help meet both the medical and non-medical needs, including ADLs, of people who cannot care for themselves for an extended period
• Not generally covered by insurance, except for long-term care insurance
• Residential facilities:
• Provide support and/or custodial care for those unable to live independently
• May have a mental or physical condition

Question 38

Nursing homes (Non-medical custodial services)

Answer 38

Provide services for those who do not require hospitalization but are unable (for reasons of physical or mental problems) to remain in their home to receive care
* Provides room, meals, and assistance with ADLs

Question 39

Respite care

Answer 39

Temporary or periodic care provided in a nursing home, assisted living residence, or other type of long-term care program to provide rest or time off for the caregiver

Question 40

Palliative care

Answer 40

*Focus is on relieving symptoms related to chronic illness
* Can be implemented at any stage of a severe or chronic illness
* Can have ongoing treatment for curative care concurrently
* Not dependent on prognosis
* Goal is to maintain quality of life by managing symptoms such as pain, dyspnea, fatigue, nausea, anorexia, depression
* Team approach to work together to anticipate, prevent and treat suffering
* May include the use of medication dosages or routes not standard
* medications used off label

Question 41

Benefit (Insurance)

Answer 41

Amount payable by a health insurance company (payor) to a healthcare provider for a client’s care (services rendered). This amount is based on the covered services in the health plan

Question 42

Carve out (Insurance)

Answer 42

Services excluded from a healthcare provider’s contract. Usually these services are
rendered under a different arrangement with other providers. For example, mental health or chemical dependency services are carved out from the agreement of a family practitioner.

Question 43

Co-insurance

Answer 43

A type of cost sharing in which the insured person pays or shares part of the medical bill. Enrollee pays a percentage, not a fixed amount, of the costs of covered healthcare services and the insurance company pays the rest. The enrollee pays co-insurance only until the agreed upon maximum amount in the plan has been reached. This arrangement assumes shared
risk between the enrollee and the insurer. Example: You have already paid the $1,000 out of
pocket (from above definition) that is your deductible. If the health insurance plan allows $100 for an office visit, and your co-insurance is 20%, then you pay $20 and insurance pays the
balance ($80).

Question 44

Deductible (Insurance)

Answer 44

Fixed amount or percentage an enrollee pays for services before the insurer begins to pay

Question 45

Enrollee (Insurance)

Answer 45

An individual who subscribes for a health benefit plan provided by a public or private healthcare insurance organization

Question 46

Health insurance plan

Answer 46

A plan that provides payment of benefits for covered sickness or injury. Included under this heading are various types of insurance (accident, disability income, medical expense, accidental death and dismemberment).

Question 47

Lifetime maximum benefit

Answer 47

Maximum amount a health insurance plan will pay to an enrollee over their lifetime.

Question 48

Out of network

Answer 48

Healthcare providers (e.g., primary care providers, specialty care providers) who do not have a contract with the plan.

Question 49

Payor

Answer 49

(Also known as insurer.) An insurance company responsible for the health insurance
benefit plan for an enrollee.

Question 50

Premium (insurance)

Answer 50

Fixed dollar amount an enrollee pays to the payor, typically on a monthly basis

Question 51

Reinsurance (Stop loss)

Answer 51

Insurance obtained to cover losses incurred while covering claims that exceed a specified dollar threshold

Question 52

Capitation

Answer 52

A fixed amount of money per-member-per-month (PMPM) paid to a provider for covered services rather than for services provided. Typical to HMOs. Payment is the same regardless of how many times the member uses the services.

Question 53

DRG/case rate (Prospective Payment)

Answer 53

Patient classification scheme that provides a means of relating the type of patient a hospital treats to the costs incurred by the hospital. It is based on groups of patients using similar resource consumption and length of stay. It classifies inpatient stays into groups for payment purposes and is used by CMS to pay hospitals for Medicare and
Medicaid recipients, but can be use by private health plans for contracting purposes

Question 54

Fee for service (FFS)

Answer 54

Providers are paid for each service performed, as opposed to capitation.
Fee schedules are an example of fee-for-service.

Question 55

Global or bundled payment

Answer 55

A predetermined all-inclusive fee for a specific set of related
services, treated as a single unit for billing or reimbursement purposes. Combines reimbursement for both facility and professional services into one lump sum payment.

Question 56

Indemnity

Answer 56

Security against possible loss or damages. Member pays provider, and then gets reimbursed, based on a predetermined amount, by the company

Question 57

Medicare Shared Savings Program

Answer 57

Key component of Medicare delivery system reform initiatives included in the ACA. Participation is voluntary in this risk sharing contract with upside and downside risks. The goal is coordinated care. Participating organizations are required to
collect and report on quality measures.

Question 58

Percent of charges (insurance)

Answer 58

Negotiated percentage rate of charges billed that will be reimbursed by the payer

Question 59

Risk sharing

Answer 59

Process whereby an HMO and contracted provider each accept a partial responsibility for the financial risk and rewards involved in cost-effectively caring for the members enrolled in the plan and assigned to a specific provider.

Question 60

Third-party administers (TPA) (insurance)

Answer 60

Organization outside of the insuring organization that handles only administrative functions (utilization review, claims processing). Used by organizations that actually fund the health benefits.

Question 61

Stop loss (insurance)

Answer 61

Used to share risk in complex clients. Payment may increase after a specific dollar threshold is met. (Hospital payment converts from DRG to percent of charges once threshold is reached.)

Question 62

Value Based Purchasing (VBP)

Answer 62

Payment based on outcomes of specific diseases. Outcomes
may include: mortality and morbidity rates; core measures; clinical outcomes; length of stay;
cost; readmission and complication rates; satisfaction with care.

Question 63

Hierarchical Condition Category (HCC)

Answer 63

Risk adjusted model originally designed to estimate future health care costs for clients. Originally used to identify Medicare high-cost chronic conditions (e.g., diabetes,
kidney failure)

Question 64

Diagnosis-related groups (DRGs)

Answer 64

System used to pay for acute inpatient care that is based primarily on a patient’s
principal diagnosis. Covers all charges (with some exceptions) for inpatient stay.

Question 65

Resource utilization groups (RUGs)

Answer 65

System used to pay for care provided in a nursing facility that is based on amount, intensity, and type of resources used, including nursing care and therapies

Question 66

Home health resource groups (HHRGs)

Answer 66

System used to pay home health agencies for services based on the resources used and the duration of the services

Question 67

International Classification of Diseases (ICD)

Answer 67

(ICD-10-CM) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States. Medical classification list by the World Health Organization (WHO).

Question 68

Current Procedural Terminology (CPT)

Answer 68

A medical code set copyrighted and maintained by the American Medical Association (AMA). Like ICD-10, except it identifies services rendered rather than diagnoses.

Question 69

The Diagnostic and Statistical Manual of Mental Disorders (DSM)

Answer 69

United States and much of the world as the authoritative guide to the diagnosis of mental disorders. DSM contains descriptions, symptoms, and other criteria for diagnosing mental disorders.