D052 Navigating Care Across the Continuum exam 2024/2025 questions and correct answers already passed

D052 Navigating Care Across the Continuum exam 2024/2025 questions and correct answers already passed When considering the regulatory requirements for healthcare, which agencies primarily oversee the use of medication? - ANSWERS 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? - ANSWERS 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? - ANSWERS 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? - ANSWERS 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? - ANSWERS 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? - ANSWERS 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? - ANSWERS 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? - ANSWERS 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? - ANSWERS Sentinal events are reportable to the government. What insurance was available prior to the 1900's? - ANSWERS 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 - ANSWERS Co-insurance Fixed amount of money paid by the insured each time a service is rendered - ANSWERS Co-payment Fixed amount of money a member must pay each year before benefits are paid by insurance company - ANSWERS Deductible Set amount paid to providers on the basis of per member, per month, regardless of amount of services used - ANSWERS Capitation Who is the gatekeeper for a patient's healthcare needs? - ANSWERS 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? - ANSWERS 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? - ANSWERS InterQual What is the purpose of the Hospital Compare website? - ANSWERS 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? - ANSWERS 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? - ANSWERS 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? - ANSWERS 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? - ANSWERS Effectiveness of Care Access/Availability of Care Experience of Care Utilization and Risk-Adjusted Utilization Health Plan Descriptive Informatio