D052-Navigating Care Across the Continuum Study Guide (UNIT 2-3-4-5-7-8-9) 2023 WITH CORRECT AND DETAILED ANDWERS

Unit 2: Application of regulation (10%) 1. Define compliance: • the process of following rules, regulations, and lawsthat r/t healthcare practices. 2. What is the importance of accurate documentation? • Protects patients • Promotes patientsafety • Promotes quality of care • Ensures patients get the right care at the right time • Reimbursement 3. Why is noncompliance an important concern for the HSC? • Noncompliance is the willful refusal to follow recommended care plans and can be the result of many different circumstances. • Reimbursement will be affected when based off-of valued care due to outcomes not being reached 4. What are bundle payments? • The reimbursement of health care providers such as hospitals and physicians on the basis of expected costs for clinically defined episodes of care. 5. What is the purpose of clinical reviews? • Clinical review isthe process of retrospectively examining potential errors or gaps in medical care, with a goal of future practice improvement. 6. What is HEDIS? • Healthcare effectiveness data and information set Comprehensive set ofstandardized performance measures designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance 7. Explain third party insurance reimbursement: • Third party payers pay for covered insurance expensesfor an insurance recipient or designated beneficiary. 8. Explain the following terms: • Co-insurance: requires the insured individual to pay a fixed percentage of the loss after the deductible has been paid • Co-payment: a specific amount of money a pt pays for a particular service • Deductible: amount you must pay before you begin to receive benefits from your insurance company. • Capitation-Payment to a provider that covers each plan member’s health care servicesfor a certain period of time. 9. What is your understanding of InterQual? • Organizesresources utilization • Objective evidence-based criteria for assessing appropriate care for pts • Helps reduce fraud and abuse 10. What is the focus on the PCMH model of care? • A care delivery model whereby pt tx is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand. 11. What are the basic components of the QI process?