WGU C425 Study guide Topic 1(Healthcare Delivery Systems, Regulation, and Compliance
Topic 1 of 5) Questions with Correct Answers 100% Verified| Guaranteed Success
Define Health? a complete state of physical, mental, and social well-being, and not merely
the absence of disease or infirmity
How have historical, cultural, and socioeconomic factors influenced the current healthcare
delivery system? increased the need for afforable univarsal cost efficient integrated
healthcare
Why should American healthcare professionals develop literacy in more holistic modes of
healthcare delivery? Because spiritual beliefs and practices positively influence physical,
mental, and social well-being and may affect the incidences, experiences, and outcomes of
many medical problems
Identify types of insurance. Medicare, Medicaid, Workers compensation, Private
Explain each type of insurance: Medicare, Medicaid/CHIP, Private "Medicare - provided
publicly financed health insurance to all elderly individuals, regardless of their incomes. Part A
and Part B of Medicare Medicaid / CHIP - covered the eligible poor and was based on the earlier
Kerr-Mills Act program. It would be financed through federal matching funds to the states in
accordance with each state's per capita income. Workers comp- covered the eligible poor and
was based on the earlier Kerr-Mills Act program. It would be financed through federal matching
funds to the states in accordance with each state's per capita income. Private - not available to
all
Explain theory of risk pooling. Sharing all risk amoung a group of insurance companies.
companies reduce their own risk because the high cost of the unhealthy is offset by the realitely
low cost of the healthier.
Explain reimbursement methods. Fee for service - Each service is reimburse Bundled
payments - a group of services (dentist, xrays, frams) Capitation - monthly payment to physician
cover visits Prospective reimbursement (PPS) - uses certain pre established criteria to
determine in advance the amount of reimbursement.
, What are the 4 types of PPS? Explain what they are Diagnosis Related Groups - DRGs
prospectively sets a bundled price according to the principal diagnosis at the time of admission.
The hospital receives the predetermined fixed rate for that particular DRG classification.
Ambulatory Payment Classifications (APCS) - divides all outpatient services into more than 300
procedural groups, with specific reimbursement rates being associated with each APC group.
The rates are also adjusted for geographic variations in wages. APC reimbursement includes
services such as anesthesia, certain drugs, supplies, and recovery room charges in a package
price established by Medicare. Resource Utilization Groups (RUGS) - categories are used for
determining an SNF's overall severity of health conditions requiring medical and nursing
intervention. The aggregate of clinical severity in a facility is referred to as its case mix. It is
determined by first evaluating each patient's medical and nursing care needs. Based on this
evaluation, each patient is classified into one of 66 RUGs (according to RUG-IV classifications).
Home Health Resource Groups - home health care pays a fixed, predetermined rate for each
60-day episode of care, regardless of the specific services delivered. Thus all services provided
by a home health agency are bundled under one payment made on a per-patient basis.
How does demand-side rationing create obstacles to obtaining healthcare, and will current and
proposed changes remove some of these obstacles? Demand side rationing create obstacles
with prices and ability to pay limit or ration the quantity and type of services consumed. current
changes with ACA is that we bome more social market rather than martet just. This will remove
ability to pay, but will most likely incrase rationing tech / supply.
Explain Medicare and Medicaid legislation. It established Medicare, a health insurance
program for the elderly, and Medicaid, a health insurance program for people with limited
income.
How have Medicare and Medicaid removed barriers and expanded access to care?
decreased disparities increased initiatives to Offord move coverage
How can your clinic ensure that it is in compliance with Medicaid policies, and how are these
policies enforced? Obtain a certification to gain compliance- enforced and maintained by
survey inspections
Topic 1 of 5) Questions with Correct Answers 100% Verified| Guaranteed Success
Define Health? a complete state of physical, mental, and social well-being, and not merely
the absence of disease or infirmity
How have historical, cultural, and socioeconomic factors influenced the current healthcare
delivery system? increased the need for afforable univarsal cost efficient integrated
healthcare
Why should American healthcare professionals develop literacy in more holistic modes of
healthcare delivery? Because spiritual beliefs and practices positively influence physical,
mental, and social well-being and may affect the incidences, experiences, and outcomes of
many medical problems
Identify types of insurance. Medicare, Medicaid, Workers compensation, Private
Explain each type of insurance: Medicare, Medicaid/CHIP, Private "Medicare - provided
publicly financed health insurance to all elderly individuals, regardless of their incomes. Part A
and Part B of Medicare Medicaid / CHIP - covered the eligible poor and was based on the earlier
Kerr-Mills Act program. It would be financed through federal matching funds to the states in
accordance with each state's per capita income. Workers comp- covered the eligible poor and
was based on the earlier Kerr-Mills Act program. It would be financed through federal matching
funds to the states in accordance with each state's per capita income. Private - not available to
all
Explain theory of risk pooling. Sharing all risk amoung a group of insurance companies.
companies reduce their own risk because the high cost of the unhealthy is offset by the realitely
low cost of the healthier.
Explain reimbursement methods. Fee for service - Each service is reimburse Bundled
payments - a group of services (dentist, xrays, frams) Capitation - monthly payment to physician
cover visits Prospective reimbursement (PPS) - uses certain pre established criteria to
determine in advance the amount of reimbursement.
, What are the 4 types of PPS? Explain what they are Diagnosis Related Groups - DRGs
prospectively sets a bundled price according to the principal diagnosis at the time of admission.
The hospital receives the predetermined fixed rate for that particular DRG classification.
Ambulatory Payment Classifications (APCS) - divides all outpatient services into more than 300
procedural groups, with specific reimbursement rates being associated with each APC group.
The rates are also adjusted for geographic variations in wages. APC reimbursement includes
services such as anesthesia, certain drugs, supplies, and recovery room charges in a package
price established by Medicare. Resource Utilization Groups (RUGS) - categories are used for
determining an SNF's overall severity of health conditions requiring medical and nursing
intervention. The aggregate of clinical severity in a facility is referred to as its case mix. It is
determined by first evaluating each patient's medical and nursing care needs. Based on this
evaluation, each patient is classified into one of 66 RUGs (according to RUG-IV classifications).
Home Health Resource Groups - home health care pays a fixed, predetermined rate for each
60-day episode of care, regardless of the specific services delivered. Thus all services provided
by a home health agency are bundled under one payment made on a per-patient basis.
How does demand-side rationing create obstacles to obtaining healthcare, and will current and
proposed changes remove some of these obstacles? Demand side rationing create obstacles
with prices and ability to pay limit or ration the quantity and type of services consumed. current
changes with ACA is that we bome more social market rather than martet just. This will remove
ability to pay, but will most likely incrase rationing tech / supply.
Explain Medicare and Medicaid legislation. It established Medicare, a health insurance
program for the elderly, and Medicaid, a health insurance program for people with limited
income.
How have Medicare and Medicaid removed barriers and expanded access to care?
decreased disparities increased initiatives to Offord move coverage
How can your clinic ensure that it is in compliance with Medicaid policies, and how are these
policies enforced? Obtain a certification to gain compliance- enforced and maintained by
survey inspections
