WGU C425 END OF COURSE EXAM QUESTIONS AND
ANSWERS GUARANTEE A+
✔✔public - ✔✔government ownership (federal,state, local) 25% of us hospitals, only
state/local hospitals are open to general public
✔✔veterans administration - ✔✔the largest federal hospital system with 150 hospitals
✔✔general hospitals - ✔✔provide a variety and broad set of services for various
conditions, general and specialized medical, obstetrics, diagnostics, treatment, surgery,
most hospitals in the US
✔✔osteopathic - ✔✔community general hospitals, holistic approach to treatment, in
addition to traditional allopathic appproach
✔✔MCOs - ✔✔garnered enormous buyhing power by enrolling a large segment of the
insured population and taking responsibility to procedure cost effective health care for
enrollees
✔✔Managed care - ✔✔mechanism for providing health care services where a single
organization takes on the management of financing, insurance, delivery, payment
✔✔capitiaiton - ✔✔the provider is paid a fixed monthly sum per enrollee often called per
member per month PMPM
✔✔discounted fees - ✔✔a modified form of fee for service
✔✔MCOS - ✔✔accredited by the national committee for quality assurance
NCQA
✔✔HEDIS data - ✔✔incorporate a number of different measures on cost and quality
amounts off the regular fees often range between 25-35%
✔✔What are the 3 jobs of MCOs - ✔✔Expert evaluation of what services are medically
necessary.
Determination of how services can be provided most inexpensively (e.g., outpatient vs
inpatient).
Review the course of medical treatment (e.g., when a patient is in the hospital).
✔✔utilization review - ✔✔process of evaluating the appropriateness of services
provided
✔✔prospective utilization review - ✔✔the medical necessity for certain treatments is
determined before the care is delivered-prevent unnecessary treatments
, ✔✔retrospective utilization review - ✔✔-managing utilization after services have already
been delivered
-based on an examination of medical records to assess the appropriateness of care
-overutilization or underutilization are examined
✔✔concurrent utilization review - ✔✔Appropriateness is determined during the course
of health care utilization. The most common example is monitoring the length of
inpatient stays.
✔✔Independent Practice Association (IPA) - ✔✔has been the most successful in terms
of enrollment, establishes contracts with solo and group practices, functions as an
intermediary representing many physicians
✔✔PPOs - ✔✔make discounted fee arrangements with providers
✔✔Integrated delivery system - ✔✔integration of several organizations under the same
ownership, provides an array of health care services to a large community
✔✔How do most americans recieve care? - ✔✔Managed care
✔✔Cost savings - ✔✔have been achieved while quality is maintained
✔✔integration - ✔✔allowed large health organizations to win sizable insurance plans
✔✔retirement facility - ✔✔emphasis on privacy, security, independence, active
lifestyles, nursing care is not provided
✔✔organized programs - ✔✔socializing, physical fitness, recreation, shopping and
entertainment, some offer hotel services-one meal a day and periodic housekeeping
✔✔Personal care facilites - ✔✔non-medical custodial care, basic assistance in a
protected environment-ADLs assisance
✔✔Skilled nursing facility - ✔✔provide full range of clinical long term care services
✔✔skilled nursing care - ✔✔medically oriented care provided by a licensed nurse
✔✔subacute care - ✔✔blend of intensive medical, nursing, and other services that are
technically complex and provided in an LTC setting-cheaper hospital alternative
✔✔snf certification - ✔✔medicare
✔✔NF certification - ✔✔medicaid
ANSWERS GUARANTEE A+
✔✔public - ✔✔government ownership (federal,state, local) 25% of us hospitals, only
state/local hospitals are open to general public
✔✔veterans administration - ✔✔the largest federal hospital system with 150 hospitals
✔✔general hospitals - ✔✔provide a variety and broad set of services for various
conditions, general and specialized medical, obstetrics, diagnostics, treatment, surgery,
most hospitals in the US
✔✔osteopathic - ✔✔community general hospitals, holistic approach to treatment, in
addition to traditional allopathic appproach
✔✔MCOs - ✔✔garnered enormous buyhing power by enrolling a large segment of the
insured population and taking responsibility to procedure cost effective health care for
enrollees
✔✔Managed care - ✔✔mechanism for providing health care services where a single
organization takes on the management of financing, insurance, delivery, payment
✔✔capitiaiton - ✔✔the provider is paid a fixed monthly sum per enrollee often called per
member per month PMPM
✔✔discounted fees - ✔✔a modified form of fee for service
✔✔MCOS - ✔✔accredited by the national committee for quality assurance
NCQA
✔✔HEDIS data - ✔✔incorporate a number of different measures on cost and quality
amounts off the regular fees often range between 25-35%
✔✔What are the 3 jobs of MCOs - ✔✔Expert evaluation of what services are medically
necessary.
Determination of how services can be provided most inexpensively (e.g., outpatient vs
inpatient).
Review the course of medical treatment (e.g., when a patient is in the hospital).
✔✔utilization review - ✔✔process of evaluating the appropriateness of services
provided
✔✔prospective utilization review - ✔✔the medical necessity for certain treatments is
determined before the care is delivered-prevent unnecessary treatments
, ✔✔retrospective utilization review - ✔✔-managing utilization after services have already
been delivered
-based on an examination of medical records to assess the appropriateness of care
-overutilization or underutilization are examined
✔✔concurrent utilization review - ✔✔Appropriateness is determined during the course
of health care utilization. The most common example is monitoring the length of
inpatient stays.
✔✔Independent Practice Association (IPA) - ✔✔has been the most successful in terms
of enrollment, establishes contracts with solo and group practices, functions as an
intermediary representing many physicians
✔✔PPOs - ✔✔make discounted fee arrangements with providers
✔✔Integrated delivery system - ✔✔integration of several organizations under the same
ownership, provides an array of health care services to a large community
✔✔How do most americans recieve care? - ✔✔Managed care
✔✔Cost savings - ✔✔have been achieved while quality is maintained
✔✔integration - ✔✔allowed large health organizations to win sizable insurance plans
✔✔retirement facility - ✔✔emphasis on privacy, security, independence, active
lifestyles, nursing care is not provided
✔✔organized programs - ✔✔socializing, physical fitness, recreation, shopping and
entertainment, some offer hotel services-one meal a day and periodic housekeeping
✔✔Personal care facilites - ✔✔non-medical custodial care, basic assistance in a
protected environment-ADLs assisance
✔✔Skilled nursing facility - ✔✔provide full range of clinical long term care services
✔✔skilled nursing care - ✔✔medically oriented care provided by a licensed nurse
✔✔subacute care - ✔✔blend of intensive medical, nursing, and other services that are
technically complex and provided in an LTC setting-cheaper hospital alternative
✔✔snf certification - ✔✔medicare
✔✔NF certification - ✔✔medicaid
