WGU D052--Navigating Care Across the Continuum Questions and Answers 2023.

WGU D052--Navigating Care Across the Continuum Questions and Answers 2023. Social Security Act governs what governs funding and requirements for Medicare, Medicaid, CHIP, and more. HIPAA and the HITECH Act protect what? protect patient privacy, requiring healthcare organizations to implement measures to keep patient records secure. The False Claims Act makes it illegal to file a false claim for funds from a federal program. The Patient Protection and Affordable Care Act implemented what? implemented new requirements for insurance, Medicaid, and more. The Drug Enforcement Administration and the Food and Drug Administration regulate what? regulate the creation and distribution of medication. The Department of Health and Human Services and the Office of the Inspector General help protect against what?. Fraud True or False. Medicare and Medicaid regulations occur at both state and federal levels. True Occupational Safety and Health Administration and the Equal Employment Opportunity Commission oversee What?? regulations. Workplace regulations KNOW your shared decision and patient centered models !! FOr this class (from FB page) ... Mike Armstrong Advocate for patient safety after having a blood test mis-read that showed he had leukemia. Donated over 15 million dollars to John Hopkins to develop programs for patient safety and diagnostic excellence. Common reason for data breaches of PHI criminal attacks (cyber attacks) HIPAA security rule covers what PHI (electronic format) of medical records When considering the regulatory requirements for healthcare, which agencies primarily oversee the use of medication? FDA and DEA Medicare and Medicaid focus on specific groups of people. Individuals over the age of 65 and disabled individuals are the current focus of what? Medicare Medicare = Federal coverage for people over 65, certain people under 65 with disabilities and people of any age with end stage renal disease Medicaid = Cooperative federal and state healthcare coverage for low-income adults, pregnant women, and children Medicare part Part A Part B Part C Part D Part A-Hospital Insurance Part B-Medical Insurance Part C- Medicare Advantage (HMO includes A&B) Part D- Prescription Drug Qualified Medicare Beneficiary (QMB) Program: Helps pay premiums, deductibles, coinsurance, and copayments for Part A, Part B, or both programs Specified Low-Income Medicare Beneficiary (SLMB) Program: Helps pay Part B premiums Qualifying Individual (QI) Program: Helps pay Part B premiums Qualified Disabled Working Individual (QDWI) Program: Pays the Part A premium for certain disabled and working beneficiaries who have disabilities Medicare Part A helps cover what Inpatient hospital care ● Skilled nursing facility care ● Hospice care ● Home health care Medicare Part B helps cover what Services from doctors and other health care providers ● Outpatient care ● Home health care ● Durable medical equipment ● Many preventive services Medicare Part C covers what includes all benefits and services covered under Part A and Part B and may include extra benefits and services for an extra cost. Medicare part D covers helps cover the cost of Prescription drugs Name other types of healthcare coverage Private insurance coverage (such as group health plan or retiree coverage) ● TRICARE ● COBRA ● Workers' Compensation ● Liability insurance coverage Bundled payments Bundle payments or episode payment models (EPMs) are an alternative means of payment that encourage organizations to coordinate services to improve the efficiency of care. Bundled payments are negotiated by CMS and third-party payors to identify the total allowable expenditures (target price) for a specific group of services. These payments are predetermined and agreed upon by the payor and payee. If Medicare and Medicaid billing is acceptable to the organization, then bundled payment services are already established. Value based services Value-based services assist in keeping the cost down. Organizations work to provide services without exceeding the established cost. If possible, the organization will attempt to increase its payment by providing less expensive services. This has allowed organizations to work together to form purchasing groups. Due to the discounts received, organizational profitability is improved TPA Third Party Administrator Why are medical bills rejected by insurance? Rejections can occur for many reasons but usually occur when there is not enough documentation to support the claim or when information is misfiled in a chart. Insurance Rejections error was caught early in the claim's lifecycle and the claim won't be accepted into the system. (Could be due to incorrect name, DOB, address, ID# etc) Insurance Denials The claim has been entered into the payer's system for adjudication, was reviewed by their claim department, and was denied.