question

The difference between an integrated delivery system and a primary care network is:

answer

Both a and b.

question

Utilization management refers to procedures implemented to

answer

Manage utilization of health care services.

question

The stages of the billing process include:

answer

Services and items are provided and recorded in the patient's medical record and coded.

question

Utilization management procedures are implemented by various health care payers to:

answer

Offer comprehensive health care services to members, cost efficiently

question

An organization consisting of a network of providers that are organized within a health system to offer patients a full range of managed health services is a(n): Answer

answer

Integrated Delivery System

question

A review conducted by a physician where all records pertinent to the patient stay are reviewed within a specified period after the patient is discharged, to determine if the care provided during the inpatient stay was appropriate based on the patient's diagnosis, is called the:

answer

Utilization review process

question

A primary care network is:

answer

Network of physicians, hospitals, and other providers integrated within a health care delivery system organized to provide health care services to patients.

question

A not-for-profit organization is one that:

answer

Is formed for the purpose of providing some service that is designed to benefit the community.

question

Creation of the Department of Health, Education and Welfare (HEW), Occupational Safety and Health Act (OSHA), The Privacy Act, and the Patient Self-Determination Act (PSDA) are legislative actions designed to address

answer

Issues related to the health, education, and welfare of the public

question

The department that is responsible for facilities and services provided to veterans of the U.S. Armed Services

answer

Department of Veterans Affairs

question

Minimum state licensing requirements indicate hospitals must have this organized group, to whom the governing authority delegates responsibility for maintaining proper standards for medical and other health care. This requirement pertains to:

answer

Medical staff.

question

The government's influence on health care expanded with the creation of what programs?

answer

Medicare and Medicaid

question

List three focus areas of governmental responsibility related to health care.

answer

Quality of patient care, improve public health, and control health care costs

question

The mission of this state regulatory agency includes promoting public health and health and safety of all state residents through disease prevention and ensuring quality medical care is provided.

answer

Department of Health

question

Acronyms for coding credentials available through the AAPC include:

answer

CPC and CPC-H.

question

Minimum licensing requirements include provisions that state hospitals must have at least one the following

answer

Inpatient beds.

question

Four federal regulatory agencies involved in the regulation of health care in hospitals are:

answer

Department of Health and Human Services, Department of Veterans Affairs, Department of Defense, and Department of Labor

question

When are hospitals allowed to bill for physician services provided in a hospital-based clinic?

answer

When the physician is employed by the hospital

question

Hospital functions are generally categorized according to a grouping of specific tasks that highlight the following four major areas:

answer

Administrative, financial, operational, and clinical

question

Hospitals maintain an inventory of rooms available in the hospital that patients are assigned to as they are admitted. The inventory is called

answer

Census

question

Which of the following services is not considered an outpatient service?

answer

Pathology department

question

Hospitals bill for this portion of services when patients are seen in the Emergency Department by a physician who is not employed by or under contract with the hospital.

answer

Technical

question

Which functional category relates to planning, organizing, and controlling finances

answer

Financial

question

Care provided to a patient who is admitted on an inpatient basis is ordered by the:

answer

Admitting Physician

question

When billing for ambulatory surgery services, the hospital bills for which portion of services?

answer

Technical

question

Financial functions are critical to the hospital maintaining a sound financial base. The role that billing and coding professionals play in maintaining a

answer

Accurate billing and coding.

question

Minimum state licensing requirements indicate hospitals must have this organized group, to whom the governing authority delegates responsibility for maintaining proper standards for medical and other health care. This requirement pertains to:

answer

Medical staff.

question

List three focus areas of governmental responsibility related to health care.

answer

Quality of patient care, improve public health, and control health care costs

question

This government agency oversees the federal responsibilities for the Medicare and Medicaid programs.

answer

Centers for Medicare and Medicaid Services

question

Creation of the Department of Health, Education and Welfare (HEW), Occupational Safety and Health Act (OSHA), The Privacy Act, and the Patient Self-Determination Act (PSDA) are legislative actions designed to address:

answer

Issues related to the health, education, and welfare of the public

question

Four federal regulatory agencies involved in the regulation of health care in hospitals are:

answer

Department of Health and Human Services, Department of Veterans Affairs, Department of Defense, and Department of Labor

question

The department that is responsible for facilities and services provided to veterans of the U.S. Armed Services.

answer

Department of Veterans Affairs

question

The mission of this state regulatory agency includes promoting public health and health and safety of all state residents through disease prevention and ensuring quality medical care is provided.

answer

Department of Health

question

Creation of the Department of Health, Education and Welfare (HEW), Occupational Safety and Health Act (OSHA), The Privacy Act, and the Patient Self-Determination Act (PSDA) are legislative actions designed to address:

answer

Issues related to the health, education, and welfare of the public.

question

This government agency oversees the federal responsibilities for the Medicare and Medicaid programs.

answer

Centers for Medicare and Medicaid Services

question

Minimum licensing requirements include provisions that state hospitals must have at least one the following:

answer

Inpatient beds.

question

Acronyms for coding credentials available through the AAPC include:

answer

CPC and CPC-H.

question

The stages of the billing process include:

answer

Services and items are provided and recorded in the patient's medical record and coded.

question

A primary care network is:

answer

Network of physicians, hospitals, and other providers integrated within a health care delivery system organized to provide health care services to patients.

question

Utilization management procedures are implemented by various health care payers to:

answer

Offer comprehensive health care services to members, cost efficiently.

question

Utilization management refers to procedures implemented to:

answer

Manage utilization of health care services.

question

A patient is considered an inpatient when:

answer

The patient is admitted to the hospital for longer than 24 hours

question

When are hospitals allowed to bill for physician services provided in a hospital-based clinic?

answer

When the physician is employed by the hospital

question

Financial functions are critical to the hospital maintaining a sound financial base. The role that billing and coding professionals play in maintaining a sound financial base includes:

answer

Accurate billing and coding.

question

Hospitals maintain an inventory of rooms available in the hospital that patients are assigned to as they are admitted. The inventory is called:

answer

Census

question

When billing for ambulatory surgery services, the hospital bills for which portion of services?

answer

Technical

question

Hospital functions are generally categorized according to a grouping of specific tasks that highlight the following four major areas:

answer

Administrative, financial, operational, and clinical

question

Care provided to a patient who is admitted on an inpatient basis is ordered by the:

answer

Admitting physician.

question

Which functional category relates to planning, organizing, and controlling finances?

answer

Financial

question

Hospitals bill for this portion of services when patients are seen in the Emergency Department by a physician who is not employed by or under contract with the hospital.

answer

Technical

question

Which of the following services is not considered an outpatient service?

answer

Pathology department

question

When billing for ambulatory surgery services, the hospital bills for which portion of services?

answer

Technical

question

Accounts receivable

answer

The term that describes monies owed to the hospital from patients, insurance companies, and government programs.

question

Acute care facility

answer

A facility designed to treat patients who have sudden onset of a condition, illness, or disease.

question

Ambulatory surgery

answer

A surgery that is performed on the same day the patient is released.

question

American College of Surgeons (ACS)

answer

Organization formed in 1913 for the purpose of developing hospital standards by collecting patient care data.

question

American Hospital Association (AHA)

answer

Organization formed in 1906 to promote public welfare by improving health care provided in hospitals.

question

American Medical Association (AMA)

answer

Organization formed in 1847, with a mission to improve standards of medical education.

question

Blue Cross

answer

Organization that introduced one of the ﬁrst prepaid health plans in 1929 to provide coverage for hospital care.

question

Coding

answer

The process of translating written descriptions of diagnoses, services, and items into numeric or alphanumeric codes.

question

Community hospital

answer

A hospital that provides care to members of a speciﬁc community.

question

Demographic information

answer

Speciﬁc characteristic information about a patient including: name, address, date of birth, sex, and Social Security number.

question

Diagnosis Related Group (DRG)

answer

A reimbursement method implemented under PPS that pays hospitals a ﬁxed amount for a hospital inpatient stay regardless of the amount of charge accrued.

question

Diagnostic service

answer

A service performed to diagnose a patient's condition.

question

Emergency Department

answer

Services are provided to patients who present with conditions that they believe require immediate attention.

question

Evaluation and management (E/M)

answer

A service performed to evaluate and manage a patient's condition, which includes a history, exam, and medical decision making by the provider.

question

Fee-for-service

answer

A payment method used by various payers that reimburses providers based on charges submitted.

question

General hospital

answer

Designed to provide medical, surgical, and emergency services required to treat a wide range of illness and injury.

question

Group health insurance

answer

Health insurance to provide coverage for medical services to members of a group. Group health insurance is often sold to employer groups or associations.

question

Hill-Burton Act

answer

Legislation implemented in 1946 that made funding available to modernize existing hospitals and build new ones

question

Hospital

answer

A facility where patients with health care problems can go to seek diagnosis and treatment of their condition(s).

question

Hospital Standardization Program

answer

Program designed by the American College of Surgeons (ASC) in 1913 to establish standards for hospital medical care.

question

Indigent

answer

A person who has no means of paying for medical services or treatments and who is not eligible for beneﬁts under Medicaid or other public assistance program.

question

Inpatient

answer

Patient care services are provided to a patient who is admitted to the hospital for more than 24 hours.

question

Insurance information

answer

Information regarding the insurance plan or government program that the patient is insured under including: plan name and number, identiﬁcation number, group name.

question

Integrated delivery system

answer

An organization consisting of a network of providers that are afﬁliated within the system to offer patients a full range of managed health care services.

question

Joint Commission on Accreditation of Healthcare

answer

Organizations (JCAHO) A national commission formed in 1952 to develop guidelines for hospitals and other health care organizations. JCAHO evaluates and accredits health care organizations based on established standards of quality for operations and medical services.

question

Managed care plans

answer

Prepaid health insurance plans that incorporate the provision of coordinated health care services and cost containment measures to monitor and manage health care services provided to members of the plan.

question

Medicaid

answer

Federal program administered at the state level established under title XIX of the SSA to provide healthcare beneﬁts for medically indigent people.

question

Medicare

answer

A government program that provides coverage for health expenses to individuals over age 65 and other eligible groups such as the disabled.

question

Non-patient

answer

A laboratory or pathology service is performed on specimens received at the hospital. The patient is not present when the service is performed

question

Observation

answer

A patient is admitted to a facility for the purpose of being observed and is generally released within 24 hours.

question

Outpatient

answer

Patient care services are provided and the patient is released within 24 hours.

question

Palliative service

answer

A service provided to chronically ill patients to help alleviate symptoms of their illness.

question

Payer

answer

Insurance company or government program that pays health beneﬁts for patient care services.

question

Peer review

answer

A review of a medical case conducted by a physician to determine or assess the medical services.

question

Peer review organization (PRO)

answer

An organization that conducts medical reviews to determine whether the quality of care, medical necessity, and appropriateness of service criteria were met.

question

Per diem

answer

A payment method used by various payers that reimburses providers for a daily rate for services.

question

Percentage of accrued charges

answer

A reimbursement method that calculates payment based on a percentage of total charges submitted.

question

Prepaid health plan

answer

A Health plan that provides health beneﬁts for speciﬁed medical services in exchange for prepayment of an annual or monthly premium.

question

Preventive service

answer

A service provided to promote wellness and prevent illness.

question

Accreditation

answer

The process by which an organization or agency performs an external review and grants recognition to a program of study or institution that meets certain predetermined standards.

question

Admitting privileges

answer

Granted to health care professionals to deﬁne what categories of patients can be seen by the professional along with the type of services and procedures that can be performed within the hospital.

question

Agency for Health Care Administration (AHCA)

answer

A regulatory agency in Florida created in 1992 under the Health Care Reform Act of 1992 for the purpose of ensuring that efﬁcient quality health care services are accessible to all Floridians.

question

American Academy of Professional Coders (AAPC)

answer

National organization founded for the purpose of elevating medical coding standards by providing ongoing education, networking opportunities, certiﬁcation, and recognition of health insurance billing and coding professionals.

question

American Health Information Management Association(AHIMA)

answer

National organization founded for the purpose of setting national standards in health information management and certiﬁcation and providing support to health information management professionals.

question

American Osteopathic Association (AOA)

answer

An organization established in 1997 for the purpose of advancing the philosophy and practice of osteopathic medicine.

question

Centers for Medicare and Medicaid Services (CMS)

answer

Agency under the Department of Health and Human Services that oversees the federal responsibilities for the Medicare and Medicaid programs.CMS was formerly known as the Health Care Financing Administration (HCFA).

question

Civil Monetary Penalties Law (CMPL)

answer

A law passed in 1983 for the purpose of prosecuting cases of Medicare and Medicaid fraud. Conditions for Participation (COP)Conditions established for providers to participate in the Medicare program. Medicare's COP contains CMS rules and regulations that govern the Medicare program. Providers of service are required to follow regulations outlined in the COP implemented under the Code of Federal Regulations, Title 42.

question

Consolidated Omnibus Budget Reconciliation Act(COBRA)

answer

Legislation passed to prevent in appropriate transfer or discharge of patients from one facility to another, commonly referred to as "dumping."Continuing education units (CEUs)Credits earned by individuals when they attend an educational function. Organizations generally grant 1 CEU for each hour attended.

question

Credentialing

answer

The process followed by hospitals and other organizations for evaluating physicians to determine whether they should be granted admitting privileges.

question

Department of Health (DOH)

answer

Agency within each state that is involved in the state's health care initiatives, including promoting public health and health safety of all state residents through disease prevention and ensuring that quality medical care is provided.

question

Department of Health and Human Services (DHHS)

answer

Federal department responsible for health issues, including controlling the rising cost of health care, the health and welfare of various populations, occupational safety, and income security plans.

question

Emergency Medical Treatment and Labor Act (EMTALA)

answer

Legislation passed by Congress to ensure public access to emergency services regardless of ability to pay.

question

Federal False Claims Act

answer

Legislation passed to prevent overuse of services and uncover fraudulent activities in the Medicare and Medicaid programs.

question

Federal Register

answer

The ofﬁcial publication in which federal regulations and legal notices are published.

question

Health, Education, and Welfare (HEW)

answer

A governmental agency formed for the purpose of addressing issues related to health, education, and welfare of the people of the United States.

question

Health Information Management (HIM)

answer

A hospital department responsible for the organization, maintenance, production, storage, retention, dissemination, and security of patient information.

question

Health Insurance Portability and Accountability Act(HIPAA)

answer

Legislation implemented in phases from 1996 to 2008 to address several issues: continuity of health insurance, prevention and detection of fraud and abuse, limited coverage, access to long-term care, simpliﬁcation of the administration of health insurance standards for the claims process, and protection of the privacy of health information.

question

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

answer

A national commission formed to evaluate and accredit health care organizations based on established standards of quality for operations and medical services.

question

Occupational Safety and Health Administration (OSHA)

answer

Agency under the Department of Labor created under the OSHA Act for the purpose of developing standards and conducting site visits to determine compliance with safety standards.

question

Ofﬁce of the Inspector General (OIG)

answer

A federal agency under the DHHS that is responsible for protecting the integrity of DHHS programs, such as Medicare and Medicaid.

question

Patient Self-Determination Act (PDSA)

answer

Legislation passed in 1990 for the purpose of ensuring that individuals are informed of their rights regarding health care decisions. The act requires facilities to provide patients with information regarding a living will, durable power of attorney, and advanced directives.

question

Professional Standards Review Organization (PSRO)

answer

Organizations that contract with Medicare to conduct reviews to determine the appropriateness and medical necessity of services provided. PSROs have full authority to deny reimbursement for health care services provides to Medicare patients if the services are deemed inappropriate.

question

Accounts receivable

answer

Outstanding accounts in which money is owed by the patient, insurance company, or government program.

question

Acute

answer

Sudden onset of a condition or symptoms.

question

Admission process

answer

Tasks required to receive a patient in the hospital including obtaining demographic, insurance, and medical information, and entering the data into the computer system.

question

Ancillary services

answer

Supportive services provided by various departments, such as radiology.

question

Census

answer

Inventory of rooms available in the hospital and the patients assigned to those rooms.

question

Clinical

answer

Refers to tasks related to medical practice.

question

Emergency Department (ED)

answer

An area in the hospital where services are provided to patients presenting with a condition or illness that requires immediate attention.

question

Health Information Management (HIM)

answer

Hospital department responsible for the organization, maintenance, production, storage, retention, dissemination, and security of patient health information. HIM is sometimes referred to as Medical Records.

question

Health information system

answer

Computer system designed for hospital patient medical and billing information. History and physical (H & P)A detailed accounting of the history, physical examination, and decision making involved regarding the patient's condition on admission.

question

Medical record documentation

answer

Information regarding the patient's condition, treatment, and progress, required to support charges submitted to various payers. Documentation is maintained in a chart, called the medical record.

question

Outpatient

answer

Services are performed at the hospital and the patient is released from the hospital the same day.

question

Professional component

answer

The portion of a procedure that represents the physician's work in performing the service, such as the reading and interpretation of a radiology ﬁlm.

question

Technical component

answer

The portion of a procedure that represents the overhead utilized in performing the service, such as the technician, supplies, materials, and equipment.

question

Utilization management (UM)

answer

Focuses on monitoring health care resources utilized in the hospital for the purpose of determining whether the services are appropriate and necessary in response to the patient's condition, thereby ensuring maximum resource utilization.

UHB Chapter 1-3 – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards