When considering the regulatory requirements for healthcare, which
agencies primarily oversee the use of medication?
NIH and AHRQ
*FDA and DEA
EPA and SSA
UR and CDC
Correct! The FDA (Federal Drug Administration) and DEA (Drug
Enforcement Agency) focus on medication compliance and medication
utilization.
How would you follow up on a denied claim?
Make sure resubmissions are marked as “corrected claim” and include the
reference number from the denied claim.
What information should you supply when you are calling to discuss a
claim?
Client’s date of birth, the organization’s tax ID or NPI, info from the claim
about date of service and coding, how much is being billed.
What are the possible outcomes of the phone call that Barbara Griswold
describes?
A corrected claim will need to be submitted, you may need to speak with a
supervisor, or you may need to file an appeal.
Which statement about the role of the healthcare services coordinator
(HSC) is true?
Transition the client throughout the organization and facilitate third-party
payments.
Ensure documentation meets the highest levels of coding for that client.
*The goal of the HCS is to improve the quality of client care and
reimbursement practices through accurate documentation and to assist
the client to improve the quality of life across the continuum of care.
Identify the errors in documentation.
,Correct! The goal of care coordination is to improve the quality of care
delivery and resource management, ensure correct documentation is
available for coding, and assist the client throughout the continuum of
care.
Within this website, where is the medication management module?
Effectiveness of Care
Where would you find the mental health utilization information?
Utilization
Where would readmissions be found?
Risk-Adjusted Utilization
What do the terms HIPAA and PHI stand for?
Health Information Privacy and Portability Act; Personal Health
Information
*Health Insurance Portability; Accountability Act and Personal Health
Information
Health Information Protection and Accuracy Act; Personal Health Inquiry
Healthcare Information Protection Administration and Accountability;
Personal Health information
Correct! HIPPA and PHI are two areas where everyone is responsible for
protecting the information for the client.
When considering the regulatory requirements for healthcare, which
agencies help protect against fraud?
The Occupational Safety and Health Administration (OSHA) and the Equal
Employment Opportunity Commission (EEOC)
*The Department of Health and Human Services (DHHS) and the Office of
the Inspector General (OIG)
The Drug Enforcement Administration (DEA) and the Food and Drug
Administration (FDA)
,The Agency for Healthcare Research and Quality (AHRQ) and the National
Institutes of Health Police (NIHP)
Correct! The DHHS and the OIG help protect against fraud.
Which of the following is a valid comparison of Medicare versus Medicaid?
*Medicare is a federal health care coverage program mainly for people
over 65 and some people younger than that who have disabilities,
whereas Medicaid is a federal and state health care coverage program for
low-income adults, pregnant women, and children.
Medicare is a federal and state program with eligibility varying from state
to state, whereas Medicaid is a federal program.
Medicaid offers a supplement plan called Medigap, but Medicare does
not.
Medicare has more than 72 million beneficiaries, including 28 million
children, whereas Medicaid has fewer than 60 million beneficiaries.
Correct! Medicare is a federal health care coverage program mainly for
people over 65 and some people younger than that who have disabilities,
whereas Medicaid is a federal and state health care coverage program for
low-income adults, pregnant women, and children.
How do the reporting requirements for a sentinel event differ from those
for a less serious health outcome?
Fault should be assigned for sentinel events immediately to expedite an
investigation.
The Quality Director does not need to be notified about sentinel events
until an initial response report is finished.
Individuals involved in sentinel events should speak openly to colleagues
and reporters about the incident to promote institutional transparency.
*Sentinal events are reportable to the government.
Correct! A sentinel event is reportable to the government.
Which of the following groups were “set aside”?
Children
Elderly
, Employees’ staff and family
Veterans
Government workers
Disabled
Children
Veterans
Government workers
What insurance was available prior to the 1900’s?
Private
Free
*None
Employer
Correct! There was no insurance available prior to 1900 for most citizens.
Co-insurance: Payment by an insured
member, a share of the payment made
against a claim
Fixed amount of money paid by the insured
Co-payment
each time a service is rendered
Fixed amount of money a member must pay
Deductible each year before benefits are paid by
insurance company
Capitation
Set amount paid to providers on the basis of
per member, per month, regardless of
agencies primarily oversee the use of medication?
NIH and AHRQ
*FDA and DEA
EPA and SSA
UR and CDC
Correct! The FDA (Federal Drug Administration) and DEA (Drug
Enforcement Agency) focus on medication compliance and medication
utilization.
How would you follow up on a denied claim?
Make sure resubmissions are marked as “corrected claim” and include the
reference number from the denied claim.
What information should you supply when you are calling to discuss a
claim?
Client’s date of birth, the organization’s tax ID or NPI, info from the claim
about date of service and coding, how much is being billed.
What are the possible outcomes of the phone call that Barbara Griswold
describes?
A corrected claim will need to be submitted, you may need to speak with a
supervisor, or you may need to file an appeal.
Which statement about the role of the healthcare services coordinator
(HSC) is true?
Transition the client throughout the organization and facilitate third-party
payments.
Ensure documentation meets the highest levels of coding for that client.
*The goal of the HCS is to improve the quality of client care and
reimbursement practices through accurate documentation and to assist
the client to improve the quality of life across the continuum of care.
Identify the errors in documentation.
,Correct! The goal of care coordination is to improve the quality of care
delivery and resource management, ensure correct documentation is
available for coding, and assist the client throughout the continuum of
care.
Within this website, where is the medication management module?
Effectiveness of Care
Where would you find the mental health utilization information?
Utilization
Where would readmissions be found?
Risk-Adjusted Utilization
What do the terms HIPAA and PHI stand for?
Health Information Privacy and Portability Act; Personal Health
Information
*Health Insurance Portability; Accountability Act and Personal Health
Information
Health Information Protection and Accuracy Act; Personal Health Inquiry
Healthcare Information Protection Administration and Accountability;
Personal Health information
Correct! HIPPA and PHI are two areas where everyone is responsible for
protecting the information for the client.
When considering the regulatory requirements for healthcare, which
agencies help protect against fraud?
The Occupational Safety and Health Administration (OSHA) and the Equal
Employment Opportunity Commission (EEOC)
*The Department of Health and Human Services (DHHS) and the Office of
the Inspector General (OIG)
The Drug Enforcement Administration (DEA) and the Food and Drug
Administration (FDA)
,The Agency for Healthcare Research and Quality (AHRQ) and the National
Institutes of Health Police (NIHP)
Correct! The DHHS and the OIG help protect against fraud.
Which of the following is a valid comparison of Medicare versus Medicaid?
*Medicare is a federal health care coverage program mainly for people
over 65 and some people younger than that who have disabilities,
whereas Medicaid is a federal and state health care coverage program for
low-income adults, pregnant women, and children.
Medicare is a federal and state program with eligibility varying from state
to state, whereas Medicaid is a federal program.
Medicaid offers a supplement plan called Medigap, but Medicare does
not.
Medicare has more than 72 million beneficiaries, including 28 million
children, whereas Medicaid has fewer than 60 million beneficiaries.
Correct! Medicare is a federal health care coverage program mainly for
people over 65 and some people younger than that who have disabilities,
whereas Medicaid is a federal and state health care coverage program for
low-income adults, pregnant women, and children.
How do the reporting requirements for a sentinel event differ from those
for a less serious health outcome?
Fault should be assigned for sentinel events immediately to expedite an
investigation.
The Quality Director does not need to be notified about sentinel events
until an initial response report is finished.
Individuals involved in sentinel events should speak openly to colleagues
and reporters about the incident to promote institutional transparency.
*Sentinal events are reportable to the government.
Correct! A sentinel event is reportable to the government.
Which of the following groups were “set aside”?
Children
Elderly
, Employees’ staff and family
Veterans
Government workers
Disabled
Children
Veterans
Government workers
What insurance was available prior to the 1900’s?
Private
Free
*None
Employer
Correct! There was no insurance available prior to 1900 for most citizens.
Co-insurance: Payment by an insured
member, a share of the payment made
against a claim
Fixed amount of money paid by the insured
Co-payment
each time a service is rendered
Fixed amount of money a member must pay
Deductible each year before benefits are paid by
insurance company
Capitation
Set amount paid to providers on the basis of
per member, per month, regardless of
