Week 4

Question 1

3

Answer 1

The first insurance policies in the US started becoming popular around the time of the Civil War
These policies mostly covered accidents received when traveling by steamboat or train

Question 2

4

Answer 2

1929
Blue Cross was developed
For hospital services only

Question 3

5

Answer 3

1939
Doctors created Blue Shield
Didn’t like hospitals being in charge

Answer 4

Employer offered health insurance plans became popular during World War II
By law, companies could not compete for employees by paying a higher salary
However, there was no freeze placed on benefits

Question 5

1) Who was the first to bring up the idea of a Universal Health System?
2) Who was against this? Why?
3) Unions were against because of what?

Answer 5

1) Harry Truman (1945-53)
2) Doctors and hospitals were against because of threat of losing money
3) They liked having the benefit of health insurance for their members

Question 6

Health insurance continued to grow in popularity, however no one wanted to cover what 2 groups? Why?

Answer 6

Poor and elderly:
The poor could not afford insurance premiums
The elderly cost more to insure

Question 7

1965 President Johnson helped pass what 2 things?

Answer 7

Medicare and Medicaid

Question 8

Differentiate between Medicare and Medicaid

Answer 8

1) Medicare: Covering the elderly; part of Social Security’s; federally funded
-“old age insurance”
2) Medicaid: insurance for welfare recipients funded by federal and state governments; administered by each state
-“poor insurance”

Question 9

1) How does insurance work?
2) Name one reason TN’s Marketplace has struggled

Answer 9

1) Everyone pays a little and the sick will get the benefits
2) Not enough healthy individuals have bought insurance

Question 10

Private insurances all have what? Define this term

Answer 10

Actuarial Value: % of the cost of care that the insurance will cover
-Actuarial value is the percentage of total average costs for coveredbenefitsthat will be paid by a health insurance plan.
-70/30 PPO

Question 11

Plans with __________ actuarial value cost more; pay more up front to pay less later

Answer 11

higher

Question 12

Give 4 examples of actuarial value of insurance plans on the Marketplace

Answer 12

Bronze – 60%
Silver – 70%
Gold – 80%
Platinum –90% (90/10)

Question 13

Who has Insurance?

Answer 13

1) Employer provided
2) Eligible, and able to afford, insurance from the Marketplace (obamacare)
3) Members of the military, active and retired

Question 14

True or false: The number of uninsured ppl has decreased since 2008

Answer 14

True

Question 15

Who are the Uninsured?

Answer 15

1) Most uninsured people are in low-income families and have at least one worker in the family
2) Adults are more likely to be uninsured than children
3) People of Color are at higher risk of being uninsured

Question 16

Why are people Uninsured?

Answer 16

1) Even under the ACA, many uninsured people cite the high cost of insurance
2) No access to coverage through a job
3) Remain ineligible for financial assistance for coverage despite expansion-above cutoff
4) Additionally, undocumented immigrants are ineligible for Medicaid or Marketplace coverage

Question 17

People without insurance coverage have ________ access to care than people who are insured.

Answer 17

worse

Question 18

One in ______ uninsured adults in 2018 went without needed medical care due to cost

Answer 18

five

Question 19

True or false: The uninsured often face unaffordable medical bills when they do seek care. Explain

Answer 19

True

These bills can quickly translate into medical debt since most of the uninsured have low or moderate incomes and have little, if any, savings

Question 20

Medicare is a broad program; what does it include?

Answer 20

Hospital
Medical
Prescriptions

Question 21

Medicare:
1) Who is it available to? (3 groups)
2) How many are enrolled?
3) Who manages it?

Answer 21

1) Age 65 and older; Disabled; ESRD
2) 65 million enrolled
3) CMS (Centers for Medicare and Medicaid) (Fed government)

Question 22

Who would be dual eligible for Medicare and Medicaid?

Answer 22

1) Low income ppl who are disabled and can’t work
2) Low income ppl 65+

Question 23

Who is eligible for medicare?

Answer 23

1) People 65+
2) Ppl of any age who have kidney failure or long term kidney disease
3) Ppl who are currently disabled and can’t work

Question 24

Who is eligible for medicaid?

Answer 24

Low income ppl who:
1) Are pregnant
2) Under 19 y/o
3) 65+ y/o
4) Blind
5) Disabled
6) Ppl who need nursing home care

Question 25

True or false: Medicare won't cover nursing homes, but medicaid will

Answer 25

True

Question 26

List the ABCD of medicare

Answer 26

Part A – Inpatient-Hospital Insurance Part B –Outpatient- Supplementary Medical Insurance Part C – Medicare Advantage Plans-Private Health Insurance Part D – Prescription Coverage

Question 27

Part A medicare includes each of the following; elaborate on each: 1) Covers inpatient care received in a hospital or skilled nursing facility 2) Home health care 3) Hospice care

Answer 27

1) Includes a semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies needed ; 100 days 2) Include medically necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology, and continuing occupational therapy 3) people with a terminal illness who are expected to live six months or less

Question 28

Part B of Medicare: What does it include?

Answer 28

1) Covers doctors’/providers’ services and outpatient care 2) Covers some other medical services that Part A doesn’t cover, such as the services of physical and occupational therapists. 3) Home health care is provided under Medicare Part B for individuals who are not covered under Medicare Part A. 4) Ambulance, lab services, diabetic supplies, doctor services, durable medical equipment, emergency room services, some vaccinations, screening mammograms, outpatient mental health services, tests, and certain transplants.

Question 29

Describe part C of medicare

Answer 29

1) Medicare Part C or Medicare Advantage plans provide an alternative to coverage under Original Medicare. (includes A&B coverage plus others) 2) Medicare Advantage is a health plan option like that of an HMO or PPO 3) Many Medicare Advantage plans include prescription drug coverage, and some plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. 4) Medicare Advantage Plans are run by private companies

Question 30

Describe part D of Medicare; what does it include? Who runs it?

Answer 30

1) Medicare prescription drug coverage began January 1, 2006 2) Helps to pay for brand name and generic drugs 3) All drugs, which includes vaccinations 4) The drug plans are run by commercial insurance companies and other private companies 5) All drug plans must meet or exceed the standard drug plan benefits as defined by the government

Question 31

Describe Medigap insurance

Answer 31

1) Covers costs that Medicare does not -Private insurance 2) Only if person has Medicare A & B 3) Not permitted to enroll if pt elects Part C

Question 32

Disability benefits commence the sixth full month after the date the disability begins. 1) If a person became disabled on June 15, 2008, Social Security disability benefits would first become payable when? 2) After a person has been entitled to disability benefits for 24 months, he or she is entitled to Medicare. In this example, Medicare entitlement begins when?

Answer 32

1) December 2008. 2) December 1, 2010.

Question 33

Describe Medicare eligibility due to age

Answer 33

1) Aged 65 or older will generally be entitled to Medicare if he/ she has worked at least 10 years in Medicare-covered employment -paid the applicable FICA tax 2) Aged 65 or older may also be eligible for Medicare if his/her spouse worked at least 10 years in Medicare-covered employment. 3) Typically, Medicare coverage begins on the first day of the month in which the individual attains age 65. -The date of Medicare entitlement is, however, dependent on the month of enrollment.

Question 34

Disability benefits commence the _______ full month after the date the disability begins.

Answer 34

sixth

Question 35

Medicare: The 24-month waiting period is waived for who? When are they eligible?

Answer 35

1) Those w. Amyotrophic Lateral Sclerosis (ALS), also called Lou Gehrig’s disease. 2) These individuals are eligible for Medicare the first month of disability benefit entitlement.

Question 36

Eligibility for Medicare coverage because of End Stage Renal Disease is for patients for whom meet what criteria?

Answer 36

1) A regular course of dialysis or 2) A kidney transplant has been prescribed by a physician because a kidney transplant or regular course of dialysis is necessary to maintain life.

Question 37

List 2 criteria for eligibility for Medicare due to disability

Answer 37

1) Medical condition meets Social Security’s definition of disability 2) Medical condition is expected to last at least 12 months

Question 38

Health professionals play a vital role in the disability determination process and participate in the process in a variety of ways; give examples

Answer 38

1) Provide medical evidence on behalf of their patients 2) As CE (consultative evaluation) sources who perform, for a fee, examinations or tests that are needed 3) As full-time or part-time medical or psychological consultants reviewing claims in a DDS, in one of SSA's regional offices, or in SSA’s central office; or 4) As medical experts who testify at ALJ (administrative law judge) hearings or respond to written interrogatories from the ALJ.

Question 39

The 1997 Balanced Budget Act (BBA): 1) When was it put into effect? 2) What did it do?

Answer 39

1) January 1, 1998 2) Liberalized Medicare coverage of physician assistant (PA) services -Removed limits based on setting and place of service 

Question 40

In addition to covering PA services that are billed incident to a physician's care, Medicare now covers PA services billed separately under a PA's own NPI provided which conditions are met?

Answer 40

1) They are considered physicians' services when furnished by an allopathic or osteopathic physician 2) They are performed by a person who meets the definition of a PA 3) They are not otherwise excluded from coverage by law 4) They are performed under the supervision of a physician 5) State law allows PAs to perform the services

Question 41

1) Define capacitation 2) Who receives this?

Answer 41

1) Payments agreed upon in a contract by a health insurance company and a medical provider. 2) They are fixed, pre-arranged monthly payments received by a physician, clinic or hospital per patient enrolled in a health plan, or per capita.

Question 42

Differentiate Capitation vs Fee For Service

Answer 42

Different modes of payment for healthcare providers 1) In capitation: doctors are paid a set amount for each patient they see* 2) With FFS: doctors are paid according to what procedures are used to treat a patient *may be paid even they don’t see the pt

Question 43

Describe the Affordable Care Act (ACA)

Answer 43

1) Patient Protection and Affordable Care Act of 2010; “Obama Care” 2) 24 million additional coverage 3) Increased Medicaid 4) Preexisting conditions

Question 44

Define payer mix

Answer 44

the percentage of revenue coming from private insurance versus government insurance versus self-paying individuals

Question 45

How is payer mix % calculated?

Answer 45

By taking the total payments for the financial class, provider, service location, and/or payer and dividing it by the total amount of payments for the entire search results

Question 46

What type of billing makes it impossible to forecast and bill?

Answer 46

Payer mix billing

Question 47

1) What is the 6th leading cause of death? 2) What sets standards on quality improvement/ risk management?

Answer 47

1) Medical errors 2) National Quality forum and Joint Commission

Question 48

1) What are Quality measures? 2) What can outcomes be?

Answer 48

1) A measure that assesses the results of health care, such as clinical events, recovery, and health status. 2) Negative or positive

Question 49

Give examples of quality measures

Answer 49

1) Optimal asthma control 2) Diabetes long-term complications- admission rate 3) Controlling high blood pressure 4) Operating on wrong limb

Question 50

Give examples of Quality Improvement/Risk Management Categories

Answer 50

Surgical or Invasive Procedure Events Product or Device Events Patient Protection Events Care Management Events Environmental Events Radiologic Events Potential Criminal Events

Question 51

QI/ R: Give examples of Surgical or Invasive Procedure Events

Answer 51

A. Surgery or other invasive procedure performed on the wrong site B. Surgery or other invasive procedure performed on the wrong patient C. Wrong surgical or other invasive procedure performed on a patient D. Unintended retention of a foreign object in a patient after surgery or other invasive procedure E. Intraoperative or immediately postoperative/postprocedure death

Question 52

QI/RM: Give examples of Product or Device Events

Answer 52

A. Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting B. Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended C. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting

Question 53

QI/RM: Give examples of Patient Protection Events

Answer 53

1) Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person 2) Patient death or serious injury associated with patient elopement (disappearance) 3) Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting

Question 54

QI/ RM: Give examples of Care Management Events

Answer 54

1) Pt death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration) 2) Pt death or serious injury associated with unsafe administration of blood products 3) Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting 4) Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy 5) Patient death or serious injury associated with a fall while being cared for in a healthcare setting 6) Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting 7) Artificial insemination with the wrong donor sperm or wrong egg H. Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen 8) Patient death or serious injury resulting

Question 55

Medication errors: More than 60% of medication, 30% of laboratory, and 30% of radiology orders during the EHR reporting period are recorded using ________

Answer 55

CPOE

Question 56

QI/RM: Give examples of environmental events

Answer 56

1) Patient or staff death or serious injury associated with an electric shock during a patient care process in a healthcare setting 2) Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or are contaminated by toxic substances 3) Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a healthcare setting 4) Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting

Question 57

QI/RM: Give an example of a radiologic event

Answer 57

Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area

Question 58

QI/RM: Give examples of potential criminal events

Answer 58

1) Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider 2) Abduction of a patient/resident of any age 3) Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting 4) Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting

Question 59

When the concept of EHRs was first developed, they were supposed to do what?

Answer 59

1) Contain information from all the clinicians involved in a patient’s care  2) All authorized clinicians involved in a patient’s care can access the information to provide care to that patient 3) Also share information with other health care providers, such as laboratories and specialists 4) EHRs follow patients: to the specialist, the hospital, the nursing home, or even across the country

Question 60

1) EMRs contain what? 2) EMRs are more valuable than paper records. Why?

Answer 60

1) Notes and information collected by and for the clinicians in that office, clinic, or hospital and are mostly used by providers for diagnosis and treatment. 2) They enable providers to track data over time, identify patients for preventive visits and screenings, monitor patients, and improve health care quality.

Question 61

EMRs: 1) There's a federal mandate to use EMRs in order to keep what? 2) What 3 things do EMRs improve?

Answer 61

1) Medicare and Medicaid reimbursement 2) Improve quality, safety, efficiency of pt records -Improve care coordination -Maintain privacy

Question 62

Give examples of EMRs

Answer 62

EPIC CERNER ATHENA E-clinical

Question 63

There are 3 common types of telemedicine; list and explain each

Answer 63

1) **Interactive Medicine:** which allows patients and physicians to communicate in real-time while maintaining HIPAA compliance 2) **Store and Forward:** which permits providers to share patient information with a practitioner in another location. 3) **Remote Patient Monitoring:** which allows remote caregivers to monitor patients that reside at home by using mobile medical devices to collect data (i.e. blood sugar or blood pressure

Question 64

There was a _______% increase in Telemed during COVID19

Answer 64

154%

Question 65

Advantages of Telemedicine include what?

Answer 65

1) Seniors having the choice to age in place 2) Rural pt access 3) COVID-19: sick visits, med refills can be done without exposure to the public-safe 4) Convenience 5) Less expensive, av. out of pocket cost $50

Question 66

What are some cons to telemed?

Answer 66

1) Dropped connections 2) Poor picture and sound quality 3) Patient no-shows 4) Patients unable to schedule a telemedicine visit/lack of technology experience 5) Lack of computer/smartphone 6) Driving during telemed 7) Having to instruct pt during PE 8) Not being able to do a complete PE 9) Lack of privacy in household 10) Lack of trust for pt on video 11) Background noise 12) Lack of focus on culture, esp for non-English-speaking pts

Question 67

In  2017, the AMA passed a resolution calling for action to do what?

Answer 67

“effectively oppose the continual, nationwide efforts to grant independent practice to non-physician practitioner”

Question 68

Telemedicine: 1) Who's eligible for these services? 2) Pt must demonstrate what? 3) Providers at the distant site submit claims for telemedicine services using what?

Answer 68

1) Individuals living in rural areas and counties not classified as metropolitan statistical areas 2) Pt must demonstrate if they are located at an eligible originating site 3) The appropriate CPT code or Health Care Common Procedure Coding System (HCPCS) code.

Question 69

Use of the telehealth ____________________ certifies that the service meets the telehealth requirements.

Answer 69

Place of Service (POS) Code 02

Question 70

Telemed: 1) The ________________ is used on professional claims when providers are participating in the federal telemedicine demonstration programs. 2) New covered telehealth services are added each year in __________________________ final rule.

Answer 70

1) CQ modifier 2) CMS’ Physician Fee Schedule

Question 71

Conflict of interests include what?

Answer 71

1) Caring for pts you have a personal relationship with 2) Prescribing for family, friends 3) Caring for co-workers 4) No narcs, sleep aids, meds outside of scope of practice