WGU D052 NAVIGATING CARE ACROSS THE CONTINUUM 2023-2024 ACTUAL EXAM 200 QUESTIONS
AND CORRECT DETAILED ANSWERS
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
,WGU D052 NAVIGATING CARE ACROSS THE CONTINUUM 2023-2024 ACTUAL EXAM 200 QUESTIONS
AND CORRECT DETAILED ANSWERS
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.
,WGU D052 NAVIGATING CARE ACROSS THE CONTINUUM 2023-2024 ACTUAL EXAM 200 QUESTIONS
AND CORRECT DETAILED ANSWERS
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
, WGU D052 NAVIGATING CARE ACROSS THE CONTINUUM 2023-2024 ACTUAL EXAM 200 QUESTIONS
AND CORRECT DETAILED ANSWERS
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.
AND CORRECT DETAILED ANSWERS
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
,WGU D052 NAVIGATING CARE ACROSS THE CONTINUUM 2023-2024 ACTUAL EXAM 200 QUESTIONS
AND CORRECT DETAILED ANSWERS
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.
,WGU D052 NAVIGATING CARE ACROSS THE CONTINUUM 2023-2024 ACTUAL EXAM 200 QUESTIONS
AND CORRECT DETAILED ANSWERS
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
, WGU D052 NAVIGATING CARE ACROSS THE CONTINUUM 2023-2024 ACTUAL EXAM 200 QUESTIONS
AND CORRECT DETAILED ANSWERS
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.
