D052 Navigating Care Across the
Continuum/ D052 Navigating Care
Across the Continuum ACTUAL EXAM.
When considering the regulatory requirements for healthcare, which agencies primarily
oversee the use of medication? - ANSWER-FDA and DEA
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? - ANSWER-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? -
ANSWER-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? -
ANSWER-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? -
ANSWER-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.
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.
What do the terms HIPAA and PHI stand for? - ANSWER-Health Insurance Portability;
Accountability Act and Personal Health Information
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? - ANSWER-The Department of Health and Human Services
(DHHS) and the Office of the Inspector General (OIG)
Which of the following is a valid comparison of Medicare versus Medicaid? - ANSWER-
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 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? - ANSWER-Sentinal events are reportable to the government.
What insurance was available prior to the 1900's? - ANSWER-None
There was no insurance available prior to 1900 for most citizens.
Payment by an insured member, a share of the payment made against a claim -
ANSWER-Co-insurance
Fixed amount of money paid by the insured each time a service is rendered - ANSWER-
Co-payment
Fixed amount of money a member must pay each year before benefits are paid by
insurance company - ANSWER-Deductible
Set amount paid to providers on the basis of per member, per month, regardless of
amount of services used - ANSWER-Capitation
Who is the gatekeeper for a patient's healthcare needs? - ANSWER-General Practice
Provider
The general practice provider can be an MD, FNP, PA or other medical oversight
specialist working with a provider.
Why is it important to know insurance regulations and requirements? - ANSWER-The
importance of knowing insurance regulations and requirements is to deliver effective
and efficient care in a timely fashion while removing the burden of dealing with the
insurance company from the patient.
Which software company is considered the gold standard for providing care
coordination? - ANSWER-InterQual
What is the purpose of the Hospital Compare website? - ANSWER-To provide
information to consumers about their local hospitals for comparison
The goal is to ensure that the customer has the ability to make an informed decision on
the facility in which they want to be cared for.
A team of coordinators is creating a clinical review process for patient paperwork to
maximize compliance with insurance regulations toward the goal of reducing claim
,denials. Which two elements must be included within the review process? - ANSWER-
Cost containment and utilization management
Clinical review processes must include both cost containment and utilization
management to be effective.
Which action will assist the coordinator in identifying areas where errors in patients'
insurance paperwork are causing claim denials? - ANSWER-Analyzing EHR data
Tracking and analyzing patient records will provide for the identification of problem
areas where processes can be adjusted.
Which coordinator's task is aligned with reducing patient insurance costs? - ANSWER-
Arranging patient preventive care services
Preventive care services have proven to reduce the need for medical services and
reduce patient insurance costs.
What are the six domains of care across which HEDIS collects more than 90
measures? - ANSWER-Effectiveness of Care
Access/Availability of Care
Experience of Care
Utilization and Risk-Adjusted Utilization
Health Plan Descriptive Information
Measures Collected Using Electronic Clinical Data Systems
How many goals are included in the Affordable Healthcare Act? - ANSWER-3
The three goals are affordability, availability and cost containment.
What are the six quality improvement concepts discussed within the webpage? -
ANSWER-Establish a culture of quality
Determine and prioritize areas for improvement
Collect and analyze data
Communicate your results
Commit to ongoing evaluation
Spread your success
Healthcare needs innovative ways to improve care delivery and reduce costs. Identify
what the PDSA cycle means in relation to these healthcare objectives. - ANSWER-A
Process improvement cycle
Plan Do Study Act is a performance improvement cycle used in healthcare to improve
quality and cost analysis.
What are the three areas of value provided by Compass Training? - ANSWER-Care
Coordination
Utilization Management
Patient Transitions
, What is the National Transitions of Care Standards Framework? - ANSWER-Standards
to help organizations assess, quantify, and identify gaps in current care transition work
plan
This applies to all healthcare setting to foster effective, quality, and efficient practices in
transitional services.
What action would have broken the chain of infection? - ANSWER-Proper hand hygiene
Why is it important to follow organizational policies? - ANSWER-Policy is a written
guideline that the organization and staff follow to guide practices and to meet regulatory
requirements.
Policies are based on the EBP guidelines established by the regulating agencies.
Why is certification important? - ANSWER-For identification of the knowledge and
experience in a chosen field
Certifications require a specific amount of experience and a knowledge and application
examination.
What is the whistleblower hotline number? - ANSWER-1-800-HHS-TIPS (1-800-447-
8477)
What would you do if you suspected fraud is occurring? - ANSWER-call the whistle
blower hotline
This is an anonymous method for reporting that helps prevents retaliation.
Which of the following is a feature of the Affordable Care Act (ACA)? - ANSWER-An
end to lifetime dollar limits on what insurance companies will cover
Insurance companies can't set a dollar limit on what they spend on essential health
benefits for your care during the entire time you're enrolled in a plan.
The National Committee for Quality Assurance (NCQA) seeks to improve the quality of
healthcare by establishing and tracking more than 90 measures of care related to
providers and practitioners, which the NCQA publishes as Healthcare Effectiveness
Data and Information Set (HEDIS) and licenses for use. Who among the following is
eligible to use HEDIS results under a custom, no-cost license? - ANSWER-Public
Sector Stakeholders
NCQA supports federal, state and public-sector entities' use of HEDIS measure
specifications in their programs under a custom, no-cost license.
Which of the following is a requirement for filing a HIPAA health information privacy or
security complaint? - ANSWER-The complaint must be filed within 180 days of
knowledge of act.
This is true, although the Office for Civil Rights (OCR) may extend the 180-day period if
the filer can show "good cause."
Continuum/ D052 Navigating Care
Across the Continuum ACTUAL EXAM.
When considering the regulatory requirements for healthcare, which agencies primarily
oversee the use of medication? - ANSWER-FDA and DEA
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? - ANSWER-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? -
ANSWER-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? -
ANSWER-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? -
ANSWER-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.
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.
What do the terms HIPAA and PHI stand for? - ANSWER-Health Insurance Portability;
Accountability Act and Personal Health Information
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? - ANSWER-The Department of Health and Human Services
(DHHS) and the Office of the Inspector General (OIG)
Which of the following is a valid comparison of Medicare versus Medicaid? - ANSWER-
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 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? - ANSWER-Sentinal events are reportable to the government.
What insurance was available prior to the 1900's? - ANSWER-None
There was no insurance available prior to 1900 for most citizens.
Payment by an insured member, a share of the payment made against a claim -
ANSWER-Co-insurance
Fixed amount of money paid by the insured each time a service is rendered - ANSWER-
Co-payment
Fixed amount of money a member must pay each year before benefits are paid by
insurance company - ANSWER-Deductible
Set amount paid to providers on the basis of per member, per month, regardless of
amount of services used - ANSWER-Capitation
Who is the gatekeeper for a patient's healthcare needs? - ANSWER-General Practice
Provider
The general practice provider can be an MD, FNP, PA or other medical oversight
specialist working with a provider.
Why is it important to know insurance regulations and requirements? - ANSWER-The
importance of knowing insurance regulations and requirements is to deliver effective
and efficient care in a timely fashion while removing the burden of dealing with the
insurance company from the patient.
Which software company is considered the gold standard for providing care
coordination? - ANSWER-InterQual
What is the purpose of the Hospital Compare website? - ANSWER-To provide
information to consumers about their local hospitals for comparison
The goal is to ensure that the customer has the ability to make an informed decision on
the facility in which they want to be cared for.
A team of coordinators is creating a clinical review process for patient paperwork to
maximize compliance with insurance regulations toward the goal of reducing claim
,denials. Which two elements must be included within the review process? - ANSWER-
Cost containment and utilization management
Clinical review processes must include both cost containment and utilization
management to be effective.
Which action will assist the coordinator in identifying areas where errors in patients'
insurance paperwork are causing claim denials? - ANSWER-Analyzing EHR data
Tracking and analyzing patient records will provide for the identification of problem
areas where processes can be adjusted.
Which coordinator's task is aligned with reducing patient insurance costs? - ANSWER-
Arranging patient preventive care services
Preventive care services have proven to reduce the need for medical services and
reduce patient insurance costs.
What are the six domains of care across which HEDIS collects more than 90
measures? - ANSWER-Effectiveness of Care
Access/Availability of Care
Experience of Care
Utilization and Risk-Adjusted Utilization
Health Plan Descriptive Information
Measures Collected Using Electronic Clinical Data Systems
How many goals are included in the Affordable Healthcare Act? - ANSWER-3
The three goals are affordability, availability and cost containment.
What are the six quality improvement concepts discussed within the webpage? -
ANSWER-Establish a culture of quality
Determine and prioritize areas for improvement
Collect and analyze data
Communicate your results
Commit to ongoing evaluation
Spread your success
Healthcare needs innovative ways to improve care delivery and reduce costs. Identify
what the PDSA cycle means in relation to these healthcare objectives. - ANSWER-A
Process improvement cycle
Plan Do Study Act is a performance improvement cycle used in healthcare to improve
quality and cost analysis.
What are the three areas of value provided by Compass Training? - ANSWER-Care
Coordination
Utilization Management
Patient Transitions
, What is the National Transitions of Care Standards Framework? - ANSWER-Standards
to help organizations assess, quantify, and identify gaps in current care transition work
plan
This applies to all healthcare setting to foster effective, quality, and efficient practices in
transitional services.
What action would have broken the chain of infection? - ANSWER-Proper hand hygiene
Why is it important to follow organizational policies? - ANSWER-Policy is a written
guideline that the organization and staff follow to guide practices and to meet regulatory
requirements.
Policies are based on the EBP guidelines established by the regulating agencies.
Why is certification important? - ANSWER-For identification of the knowledge and
experience in a chosen field
Certifications require a specific amount of experience and a knowledge and application
examination.
What is the whistleblower hotline number? - ANSWER-1-800-HHS-TIPS (1-800-447-
8477)
What would you do if you suspected fraud is occurring? - ANSWER-call the whistle
blower hotline
This is an anonymous method for reporting that helps prevents retaliation.
Which of the following is a feature of the Affordable Care Act (ACA)? - ANSWER-An
end to lifetime dollar limits on what insurance companies will cover
Insurance companies can't set a dollar limit on what they spend on essential health
benefits for your care during the entire time you're enrolled in a plan.
The National Committee for Quality Assurance (NCQA) seeks to improve the quality of
healthcare by establishing and tracking more than 90 measures of care related to
providers and practitioners, which the NCQA publishes as Healthcare Effectiveness
Data and Information Set (HEDIS) and licenses for use. Who among the following is
eligible to use HEDIS results under a custom, no-cost license? - ANSWER-Public
Sector Stakeholders
NCQA supports federal, state and public-sector entities' use of HEDIS measure
specifications in their programs under a custom, no-cost license.
Which of the following is a requirement for filing a HIPAA health information privacy or
security complaint? - ANSWER-The complaint must be filed within 180 days of
knowledge of act.
This is true, although the Office for Civil Rights (OCR) may extend the 180-day period if
the filer can show "good cause."
