exam 1 Flashcards
Which of the following is TRUE about HSA’s with high deductibles?
- Beneficiaries tend to choose HSA’s if they anticipate lots of healthcare use
- Beneficiaries set up a designated bank account from which they can pay for healthcare expenses like co-pays
- Providers collect most of the payment directly from the insurer
- Insurance Networks tend to be very restricted
- Beneficiaries tend to choose HSA’s if they anticipate lots of healthcare use
* Beneficiaries set up a designated bank account from which they can pay for healthcare expenses like co-pays - Providers collect most of the payment directly from the insurer
- Insurance Networks tend to be very restricted
An insurer offering a Part C plan is most likely to experience which of the following outcomes when there are high numbers of enrollees?
Adverse Selection
Favorable Selection
Both Adverse and Favorable Selection
Neither Adverse nor Favorable Selection
Adverse Selection
Favorable Selection
Both Adverse and Favorable Selection NOT
Neither Adverse nor Favorable Selection
In which of the following settings does the number of CPT codes billed impact payment to the provider?
Prospective Payment System
Payment per diem
Fee for Service
Capitation
Payment per patient
Prospective Payment System
Payment per diem
** Fee for Service **
Capitation
Payment per patient
A beneficiary’s insurance policy is 80/20 based on provider charges. What does the 20 represent?
Percentage (20%) the patient is responsible for paying
Dollar amount ($20) the patient is responsible for paying
Percentage (20%) the insurer is responsible for paying
Dollar amount ($20) the insurer is responsible for paying
Percentage (20%) the patient is responsible for paying
Dollar amount ($20) the patient is responsible for paying
Percentage (20%) the insurer is responsible for paying
Dollar amount ($20) the insurer is responsible for paying
Reforms to PDPM primarily impacts which setting?
Acute Care Hospitals
Home Health Agencies
Skilled Nursing Facilities
Inpatient Rehab Facilities
Outpatient clinics
Skilled Nursing Facilities
Which of the following is most likely to lead to the most financial loss for an insurer (in monetary terms)?
Small and sick pool
Large and sick pool
Small and healthy pool
Large and healthy pool
Small and sick pool
** Large and sick pool **
Small and healthy pool
Large and healthy pool
Observation stays in an acute care hospital are paid by which of the following?
Private Insurance
Medicare Part A
Medicare Part B
Medicare Part B
A patient may be enrolled simultaneously in which of the following?
Medicare Part A, B and C
Medicare Part A, B and D
Medicare Part A and C
Medicare Part B, C and D
Medicare Part A, B and D
Part B Medicare co-insurance for physical therapy is what % of the Medicare Fee Schedule (also known as Medicare Allowable Charges)?
10%
20%
25%
30%
20%
Which of the following are covered services under Medicare?
Inpatient Acute Care hospitalization paid on a fee for service basis
24 hour home care paid on a fee for service basis
Custodial Care paid on a PPS model
Skilled Nursing Facility Care paid on a PDPM model
?
Skilled Nursing Facility Care paid on a PDPM model
Medicaid “Spend down” refers to:
An individual will have to cash pay for their Custodial Care until they qualify for Medicaid
An individual will only be required to spend down after Medicare completes payment for their Custodial Care
An individual will be able to move their savings into a trust for their heirs prior to “spending down”
The requirement that families can not earn over the federal poverty level to qualify for Medicaid
- An individual will have to cash pay for their Custodial Care until they qualify for Medicaid
Most Physical Therapist generated charges in an acute care hospital are used primarily to determine productivity and may not even leave the building to be billed to Medicare. Why is this?
CPT codes are only used for Part B services
The hospital is paid based on DRG
CPT codes are used internally to determine payment from Part C providers
The hospital is paid based on therapist productivity
The hospital is paid based on DRG
Medicare Advantage plans are paid on a per member, per month, risk-adjusted basis. Based on this system, what happens if the private insurer ends up with adverse selection in their pool after open enrollment?
Payment to the private insurer by Medicare goes up
Payment to the private insurer by Medicare goes down
Payment to the private insurer by Medicare does not change
Payment to the private insurer by Medicare goes up
In the context of value-based models and the triple aim, what is the definition of value?
Market worth
Health outcomes achieved per dollar spent
An amount considered to be fair or adequate
Health outcomes achieved per dollar spent
Which of the following is NOT part of the Triple Aim?
Better Health
Focus on Prevention
Better Healthcare
Cost containment
Focus on Prevention
Which of the following is considered a success with the Hospital Readmissions Reduction Program?
Increased hospital focus on social supports and discharge planning.
Reduction in observational stays
Reduction in Medicare Part B charges
Increased hospital focus on social supports and discharge planning.
An applicant for health insurance on Connect for Health Colorado can not be denied insurance due to a diagnosis of diabetes mellitus. This represents:
Adverse Selection
Individual Mandate
Community Rating
Guaranteed Issue
Guaranteed Issue
Which of the following populations fits best in the ACO payment model?
A patient with longstanding diabetes mellitus including a lower extremity amputation.
A person who experiences chronic ongoing challenges with homelessness.
A person with a supportive family who undergoes total joint replacement.
A person with a supportive family who undergoes total joint replacement.
The “Shared Responsibility Payment” can be satisfied by all of the following EXCEPT:
Medicare
A non-ACA compliant private insurance plan
Medicaid
Tricare
An employer-sponsored private insurance plan
A non-ACA compliant private insurance plan
Which of the following is TRUE about the CMMI Medical Home model?
The “Home” occurs in a building where the patient also lives.
It does not include physical therapy services.
It includes a highly involved and coordinated team of health professionals.
It includes a highly involved and coordinated team of health professionals.
Which of the following elements reflect the expected “future” healthcare business model?
Care provided in-office
Fee-for-Service
Ongoing health management
Utilization managed within a care setting
Sick care
Ongoing health management
What is a characteristic of the Comprehensive Care for Joint Replacement model?
Individuals must have a 3 night acute care hospital stay
Individuals must be homebound to receive home health services
Cost sharing occurs within a single institution only
30 day re-hospitalization rate is used as a measure of quality
Telehealth is prohibited under this model
30 day re-hospitalization rate is used as a measure of quality
The American Healthcare system has been called “sick care, not healthcare.” This reflects a deficit in which of the following?
Access
Quality
Cost
QUALITY
Members of the healthcare team always consider the impact of their decisions on other individuals and processes inside and outside of their organization. This is an example of:
Value Based Thinking
Divergent Approaches
Systems Thinking
Coordination-based Modeling
Systems Thinking
