WGU D391 Health Ecosystem Assessment Prep Worksheet Guide with Complete
Solutions | 2025 - Section 2:
This Study set tests your understanding of the complex U.S. healthcare system,
focusing on its components (Patients, Providers, Producers, Payers,
Policymakers), funding, regulation, stakeholders, quality improvement models
(like the Quadruple Aim, STEEEP domains), and h ealth services delivery. You'll
need to identify roles (e.g., care coordinators, advanced practice providers),
understand funding sources (Medicare/Medicaid), and describe how different
parts of the system interact to provide patient care, emphasizing effi ciency,
quality, an (for YR. 2026/2027)
Lesson 1:
1. How do the fundamental principles of insurance-payer models
determine healthcare accessibility and affordability?
-The US healthcare system as well as the payer systems require regulations to ensure
that people receive high-quality and safe care.
2. List and describe the 5 main funding models currently found in the
world.
-self-funded model = Individual/responsible party pays out of pocket.
-Bismarck = Everyone is covered called “sick fund”. Universal, social insurance, nonprofit
through employer. Primarily insurance funded and typically with private providers.
-Beveridge = government is principal payer and owner of healthcare system through tax
payments. Universal coverage, socialized medicine.
-National Health Insurance = government principal payer for care, providers are private.
Single payer, funded through taxes or premiums, private universal coverage.
-Hybrid Bis-Bev = Healthcare paid for by government and funding is shared between
employers and employees.
3. What is the value-based care model?
,-It is quality focused programs, where providers are paid on quality versus quantity and
meeting quality care and prevention initiatives in relation to hospital readmission
reduction, hospital-acquired condition reduction, quality payment, and hospital
valuebased purchasing. If providers do not deliver quality care, they will be held
accountable.
4. What are some impacts of limited access to healthcare?
-Low socioeconomic populations have limited access which could lead to poor health
outcomes, low life expectance, increased mental health behavior, and preventable
death. Some impacts may not be able to pay for medical services.
5. What are deductibles as related to health insurance?
-The amount of money you must pay for your care before the insurance company will
share the costs. It is a form of cost sharing between the insurer and the insurance
company.
6. What are copays as related to health insurance?
-Pay part of the cost; fee called copay. It is a fee you pay when you receive specific
health care services, like a visit. Copay is a form of cost sharing and insurance
companies will split the cost of paying for health care.
7. What is co-insurance as related to health insurance?
-It is usually a percentage of the medical cost that insurer will pay instead of a flat fee.
Co-insurance is a portion of the medical cost. It is a form of cost sharing.
8. Describe the 4 principles of insurance risk.
-Risk is unpredictable for individuals, likelihood of a healthcare event is difficult to
predict and illness or injury.
-Risk is predictable in large groups, probability of a particular healthcare. It has been
proven that in large groups, an event could be predicted accurately.
-Pooled Risk is when some people have lower risk and uses less, but if there’s serious
health issues, they will need more use of it,
-Losses are for all shared members and be shared.
9. What is a moral hazard?
-When a consumer buys additional, unnecessary healthcare because they do not receive
the full benefit. For example, when an individual has lower out of pocket, such as copay
or deductible, they are likely to receive unnecessary healthcare. Moral hazard happens
, when people consume more medical services than necessary because they don’t
acquire the full cost.
10. What is adverse selection?
-When a consumer does not purchase health insurance until they need coverage. For
example, chronic conditions and multiple health plan choices from his employer,
chooses a more generous plan. This occurs when there is an imbalance of high-risk, sick
people, requiring more insurance, using more coverage than healthy people who need
less coverage and do not buy a policy.
11. Discuss what an indemnity plan is.
-To compensate the insured against the cost of medical care up to certain policy limits.
It is a fee for service approach. Insurance pays a predetermined amount in percentage
for a service, and the insurer will pay the rest.
12. What are prospective fee schedules?
-Payments are made based on a negotiated price and the price does not necessarily
have a relationship to an existing fee schedule of the provider.
Lesson 2:
1. The Supreme Court determined that insurance should be governed at the
federal level.
2. What federal law regulates self-insured?
-The ERISA which is Employee Retirement Income Security Act. It regulates self-funded
insurance plans.
3. What is the false claims act? How does it apply to providers?
- The false claim act is when providers file false claims with insurance companies. For
example, Dr. Jones filed a medical claim for a wellness visit for a patient that never set
foot in their office. This action is considered fraud and abuse. The false claims act
prevents providers from committing fraud or claiming services that were never
rendered.
4. What is the anti-kickback statute? Give an example of a violation of this
statute.
, - when a physician receives financial incentives for referrals or drives a patient to a
specific product. For example, the doctor receives financial incentives from a a lab and
sends all the patients to that lab regardless of the insurance. Statute prohibits incentive
for referring a patient to generate business for another provider. In both scenarios, the
doctor will face penalties and, in some cases, prison time. This behavior reduces the
quality of care and increase the cost.
5. What is the difference between fraud vs abuse?
- Fraud is an intentional deception or misrepresentation of services that an individual
knows to be false and could result in an unauthorized reimbursement to a practice. Such
as, Billing for services never rendered, falsifying medical records.
-Abuse describes incidents or practices inconsistent with accepted and sound medical,
business, or fiscal practices. Such as, Billing separately for parts of a procedure when a
single code should be used, Providing unnecessary services or treatments.
6. Give 3 examples of fraud:
-Billing for services never rendered.
-Falsifying medical records.
-Submitting multiple claims for the same service
7. What is the Stark law?
- prohibits physicians from referring patients for designated health services (like lab or
imaging services) to entities in which the physician or a family member has a financial
interest, unless an exception applies. prevent conflicts of interest and protect
Medicare patients from receiving unnecessary or overpriced medical services. The
Centers for Medicare & Medicaid Services (CMS) oversees the Stark law
8. What are punishments for fraud and abuse? List 4 examples.
- Nonpayment of claims
- Civil monetary penalties
-Exclusion from all federal healthcare programs
-Civil and criminal liability, potentially including imprisonment
9. What is the Affordable Care Act (ACA)?
-The Affordable Care Act (ACA), also known as Obamacare, is a comprehensive health
care reform law enacted in 2010 aiming to make health insurance more affordable and
Solutions | 2025 - Section 2:
This Study set tests your understanding of the complex U.S. healthcare system,
focusing on its components (Patients, Providers, Producers, Payers,
Policymakers), funding, regulation, stakeholders, quality improvement models
(like the Quadruple Aim, STEEEP domains), and h ealth services delivery. You'll
need to identify roles (e.g., care coordinators, advanced practice providers),
understand funding sources (Medicare/Medicaid), and describe how different
parts of the system interact to provide patient care, emphasizing effi ciency,
quality, an (for YR. 2026/2027)
Lesson 1:
1. How do the fundamental principles of insurance-payer models
determine healthcare accessibility and affordability?
-The US healthcare system as well as the payer systems require regulations to ensure
that people receive high-quality and safe care.
2. List and describe the 5 main funding models currently found in the
world.
-self-funded model = Individual/responsible party pays out of pocket.
-Bismarck = Everyone is covered called “sick fund”. Universal, social insurance, nonprofit
through employer. Primarily insurance funded and typically with private providers.
-Beveridge = government is principal payer and owner of healthcare system through tax
payments. Universal coverage, socialized medicine.
-National Health Insurance = government principal payer for care, providers are private.
Single payer, funded through taxes or premiums, private universal coverage.
-Hybrid Bis-Bev = Healthcare paid for by government and funding is shared between
employers and employees.
3. What is the value-based care model?
,-It is quality focused programs, where providers are paid on quality versus quantity and
meeting quality care and prevention initiatives in relation to hospital readmission
reduction, hospital-acquired condition reduction, quality payment, and hospital
valuebased purchasing. If providers do not deliver quality care, they will be held
accountable.
4. What are some impacts of limited access to healthcare?
-Low socioeconomic populations have limited access which could lead to poor health
outcomes, low life expectance, increased mental health behavior, and preventable
death. Some impacts may not be able to pay for medical services.
5. What are deductibles as related to health insurance?
-The amount of money you must pay for your care before the insurance company will
share the costs. It is a form of cost sharing between the insurer and the insurance
company.
6. What are copays as related to health insurance?
-Pay part of the cost; fee called copay. It is a fee you pay when you receive specific
health care services, like a visit. Copay is a form of cost sharing and insurance
companies will split the cost of paying for health care.
7. What is co-insurance as related to health insurance?
-It is usually a percentage of the medical cost that insurer will pay instead of a flat fee.
Co-insurance is a portion of the medical cost. It is a form of cost sharing.
8. Describe the 4 principles of insurance risk.
-Risk is unpredictable for individuals, likelihood of a healthcare event is difficult to
predict and illness or injury.
-Risk is predictable in large groups, probability of a particular healthcare. It has been
proven that in large groups, an event could be predicted accurately.
-Pooled Risk is when some people have lower risk and uses less, but if there’s serious
health issues, they will need more use of it,
-Losses are for all shared members and be shared.
9. What is a moral hazard?
-When a consumer buys additional, unnecessary healthcare because they do not receive
the full benefit. For example, when an individual has lower out of pocket, such as copay
or deductible, they are likely to receive unnecessary healthcare. Moral hazard happens
, when people consume more medical services than necessary because they don’t
acquire the full cost.
10. What is adverse selection?
-When a consumer does not purchase health insurance until they need coverage. For
example, chronic conditions and multiple health plan choices from his employer,
chooses a more generous plan. This occurs when there is an imbalance of high-risk, sick
people, requiring more insurance, using more coverage than healthy people who need
less coverage and do not buy a policy.
11. Discuss what an indemnity plan is.
-To compensate the insured against the cost of medical care up to certain policy limits.
It is a fee for service approach. Insurance pays a predetermined amount in percentage
for a service, and the insurer will pay the rest.
12. What are prospective fee schedules?
-Payments are made based on a negotiated price and the price does not necessarily
have a relationship to an existing fee schedule of the provider.
Lesson 2:
1. The Supreme Court determined that insurance should be governed at the
federal level.
2. What federal law regulates self-insured?
-The ERISA which is Employee Retirement Income Security Act. It regulates self-funded
insurance plans.
3. What is the false claims act? How does it apply to providers?
- The false claim act is when providers file false claims with insurance companies. For
example, Dr. Jones filed a medical claim for a wellness visit for a patient that never set
foot in their office. This action is considered fraud and abuse. The false claims act
prevents providers from committing fraud or claiming services that were never
rendered.
4. What is the anti-kickback statute? Give an example of a violation of this
statute.
, - when a physician receives financial incentives for referrals or drives a patient to a
specific product. For example, the doctor receives financial incentives from a a lab and
sends all the patients to that lab regardless of the insurance. Statute prohibits incentive
for referring a patient to generate business for another provider. In both scenarios, the
doctor will face penalties and, in some cases, prison time. This behavior reduces the
quality of care and increase the cost.
5. What is the difference between fraud vs abuse?
- Fraud is an intentional deception or misrepresentation of services that an individual
knows to be false and could result in an unauthorized reimbursement to a practice. Such
as, Billing for services never rendered, falsifying medical records.
-Abuse describes incidents or practices inconsistent with accepted and sound medical,
business, or fiscal practices. Such as, Billing separately for parts of a procedure when a
single code should be used, Providing unnecessary services or treatments.
6. Give 3 examples of fraud:
-Billing for services never rendered.
-Falsifying medical records.
-Submitting multiple claims for the same service
7. What is the Stark law?
- prohibits physicians from referring patients for designated health services (like lab or
imaging services) to entities in which the physician or a family member has a financial
interest, unless an exception applies. prevent conflicts of interest and protect
Medicare patients from receiving unnecessary or overpriced medical services. The
Centers for Medicare & Medicaid Services (CMS) oversees the Stark law
8. What are punishments for fraud and abuse? List 4 examples.
- Nonpayment of claims
- Civil monetary penalties
-Exclusion from all federal healthcare programs
-Civil and criminal liability, potentially including imprisonment
9. What is the Affordable Care Act (ACA)?
-The Affordable Care Act (ACA), also known as Obamacare, is a comprehensive health
care reform law enacted in 2010 aiming to make health insurance more affordable and
