UHB Chapter 1-3

The difference between an integrated delivery system and a primary care network is:
Both a and b.
Utilization management refers to procedures implemented to
Manage utilization of health care services.
The stages of the billing process include:
Services and items are provided and recorded in the patient’s medical record and coded.
Utilization management procedures are implemented by various health care payers to:
Offer comprehensive health care services to members, cost efficiently
An organization consisting of a network of providers that are organized within a health system to offer patients a full range of managed health services is a(n):
Answer
Integrated Delivery System
A review conducted by a physician where all records pertinent to the patient stay are reviewed within a specified period after the patient is discharged, to determine if the care provided during the inpatient stay was appropriate based on the patient’s diagnosis, is called the:
Utilization review process
A primary care network is:
Network of physicians, hospitals, and other providers integrated within a health care delivery system organized to provide health care services to patients.
A not-for-profit organization is one that:
Is formed for the purpose of providing some service that is designed to benefit the community.
Creation of the Department of Health, Education and Welfare (HEW), Occupational Safety and Health Act (OSHA), The Privacy Act, and the Patient Self-Determination Act (PSDA) are legislative actions designed to address
Issues related to the health, education, and welfare of the public
The department that is responsible for facilities and services provided to veterans of the U.S. Armed Services
Department of Veterans Affairs
Minimum state licensing requirements indicate hospitals must have this organized group, to whom the governing authority delegates responsibility for maintaining proper standards for medical and other health care. This requirement pertains to:
Medical staff.
The government’s influence on health care expanded with the creation of what programs?
Medicare and Medicaid
List three focus areas of governmental responsibility related to health care.
Quality of patient care, improve public health, and control health care costs
The mission of this state regulatory agency includes promoting public health and health and safety of all state residents through disease prevention and ensuring quality medical care is provided.
Department of Health
Acronyms for coding credentials available through the AAPC include:
CPC and CPC-H.
Minimum licensing requirements include provisions that state hospitals must have at least one the following
Inpatient beds.
Four federal regulatory agencies involved in the regulation of health care in hospitals are:
Department of Health and Human Services, Department of Veterans Affairs, Department of Defense, and Department of Labor
When are hospitals allowed to bill for physician services provided in a hospital-based clinic?
When the physician is employed by the hospital
Hospital functions are generally categorized according to a grouping of specific tasks that highlight the following four major areas:
Administrative, financial, operational, and clinical
Hospitals maintain an inventory of rooms available in the hospital that patients are assigned to as they are admitted. The inventory is called
Census
Which of the following services is not considered an outpatient service?
Pathology department
Hospitals bill for this portion of services when patients are seen in the Emergency Department by a physician who is not employed by or under contract with the hospital.
Technical
Which functional category relates to planning, organizing, and controlling finances
Financial
Care provided to a patient who is admitted on an inpatient basis is ordered by the:
Admitting Physician
When billing for ambulatory surgery services, the hospital bills for which portion of services?
Technical
Financial functions are critical to the hospital maintaining a sound financial base. The role that billing and coding professionals play in maintaining a
Accurate billing and coding.
Minimum state licensing requirements indicate hospitals must have this organized group, to whom the governing authority delegates responsibility for maintaining proper standards for medical and other health care. This requirement pertains to:
Medical staff.
List three focus areas of governmental responsibility related to health care.
Quality of patient care, improve public health, and control health care costs
This government agency oversees the federal responsibilities for the Medicare and Medicaid programs.
Centers for Medicare and Medicaid Services
Creation of the Department of Health, Education and Welfare (HEW), Occupational Safety and Health Act (OSHA), The Privacy Act, and the Patient Self-Determination Act (PSDA) are legislative actions designed to address:
Issues related to the health, education, and welfare of the public
Four federal regulatory agencies involved in the regulation of health care in hospitals are:
Department of Health and Human Services, Department of Veterans Affairs, Department of Defense, and Department of Labor
The department that is responsible for facilities and services provided to veterans of the U.S. Armed Services.
Department of Veterans Affairs
The mission of this state regulatory agency includes promoting public health and health and safety of all state residents through disease prevention and ensuring quality medical care is provided.
Department of Health
Creation of the Department of Health, Education and Welfare (HEW), Occupational Safety and Health Act (OSHA), The Privacy Act, and the Patient Self-Determination Act (PSDA) are legislative actions designed to address:
Issues related to the health, education, and welfare of the public.
This government agency oversees the federal responsibilities for the Medicare and Medicaid programs.
Centers for Medicare and Medicaid Services
Minimum licensing requirements include provisions that state hospitals must have at least one the following:
Inpatient beds.
Acronyms for coding credentials available through the AAPC include:
CPC and CPC-H.
The stages of the billing process include:
Services and items are provided and recorded in the patient’s medical record and coded.
A primary care network is:
Network of physicians, hospitals, and other providers integrated within a health care delivery system organized to provide health care services to patients.
Utilization management procedures are implemented by various health care payers to:
Offer comprehensive health care services to members, cost efficiently.
Utilization management refers to procedures implemented to:
Manage utilization of health care services.
A patient is considered an inpatient when:
The patient is admitted to the hospital for longer than 24 hours
When are hospitals allowed to bill for physician services provided in a hospital-based clinic?
When the physician is employed by the hospital
Financial functions are critical to the hospital maintaining a sound financial base. The role that billing and coding professionals play in maintaining a sound financial base includes:
Accurate billing and coding.
Hospitals maintain an inventory of rooms available in the hospital that patients are assigned to as they are admitted. The inventory is called:
Census
When billing for ambulatory surgery services, the hospital bills for which portion of services?
Technical
Hospital functions are generally categorized according to a grouping of specific tasks that highlight the following four major areas:
Administrative, financial, operational, and clinical
Care provided to a patient who is admitted on an inpatient basis is ordered by the:
Admitting physician.
Which functional category relates to planning, organizing, and controlling finances?
Financial
Hospitals bill for this portion of services when patients are seen in the Emergency Department by a physician who is not employed by or under contract with the hospital.
Technical
Which of the following services is not considered an outpatient service?
Pathology department
When billing for ambulatory surgery services, the hospital bills for which portion of services?
Technical
Accounts receivable
The term that describes monies owed to the hospital from patients,
insurance companies, and government programs.
Acute care facility
A facility designed to treat patients who have sudden onset of a condition,
illness, or disease.
Ambulatory surgery
A surgery that is performed on the same day the patient is released.
American College of Surgeons (ACS)
Organization formed in 1913 for the purpose of developing hospital
standards by collecting patient care data.
American Hospital Association (AHA)
Organization formed in 1906 to promote public welfare by improving
health care provided in hospitals.
American Medical Association (AMA)
Organization formed in 1847, with a mission to improve standards of
medical education.
Blue Cross
Organization that introduced one of the first prepaid health plans in 1929
to provide coverage for hospital care.
Coding
The process of translating written descriptions of diagnoses, services, and
items into numeric or alphanumeric codes.
Community hospital
A hospital that provides care to members of a specific community.
Demographic information
Specific characteristic information about a patient including: name,
address, date of birth, sex, and Social Security number.
Diagnosis Related Group (DRG)
A reimbursement method implemented under PPS that pays hospitals a
fixed amount for a hospital inpatient stay regardless of the amount of
charge accrued.
Diagnostic service
A service performed to diagnose a patient’s condition.
Emergency Department
Services are provided to patients who present with conditions that they
believe require immediate attention.
Evaluation and management (E/M)
A service performed to evaluate and manage a patient’s condition, which
includes a history, exam, and medical decision making by the provider.
Fee-for-service
A payment method used by various payers that reimburses providers
based on charges submitted.
General hospital
Designed to provide medical, surgical, and emergency services required to
treat a wide range of illness and injury.
Group health insurance
Health insurance to provide coverage for medical services to members of a
group. Group health insurance is often sold to employer groups or
associations.
Hill-Burton Act
Legislation implemented in 1946 that made funding available to modernize
existing hospitals and build new ones
Hospital
A facility where patients with health care problems can go to seek diagnosis
and treatment of their condition(s).
Hospital Standardization Program
Program designed by the American College of Surgeons (ASC) in 1913 to
establish standards for hospital medical care.
Indigent
A person who has no means of paying for medical services or treatments
and who is not eligible for benefits under Medicaid or other public
assistance program.
Inpatient
Patient care services are provided to a patient who is admitted to the
hospital for more than 24 hours.
Insurance information
Information regarding the insurance plan or government program that the
patient is insured under including: plan name and number, identification
number, group name.
Integrated delivery system
An organization consisting of a network of providers that are affiliated
within the system to offer patients a full range of managed health care
services.
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO)
A national commission formed in 1952 to develop guidelines for hospitals
and other health care organizations. JCAHO evaluates and accredits health
care organizations based on established standards of quality for operations
and medical services.
Managed care plans
Prepaid health insurance plans that incorporate the provision of
coordinated health care services and cost containment measures to
monitor and manage health care services provided to members of the plan.
Medicaid
Federal program administered at the state level established under title XIX
of the SSA to provide healthcare benefits for medically indigent people.
Medicare
A government program that provides coverage for health expenses to
individuals over age 65 and other eligible groups such as the disabled.
Non-patient
A laboratory or pathology service is performed on specimens received at
the hospital. The patient is not present when the service is performed
Observation
A patient is admitted to a facility for the purpose of being observed and is
generally released within 24 hours.
Outpatient
Patient care services are provided and the patient is released within 24
hours.
Palliative service
A service provided to chronically ill patients to help alleviate symptoms of
their illness.
Payer
Insurance company or government program that pays health benefits for
patient care services.
Peer review
A review of a medical case conducted by a physician to determine or assess
the medical services.
Peer review organization (PRO)
An organization that conducts medical reviews to determine whether the
quality of care, medical necessity, and appropriateness of service criteria
were met.
Per diem
A payment method used by various payers that reimburses providers for a
daily rate for services.
Percentage of accrued charges
A reimbursement method that calculates payment based on a percentage
of total charges submitted.
Prepaid health plan
A Health plan that provides health benefits for specified medical services in
exchange for prepayment of an annual or monthly premium.
Preventive service
A service provided to promote wellness and prevent illness.
Accreditation
The process by which an organization or agency performs an external
review and grants recognition to a program of study or institution that
meets certain predetermined standards.
Admitting privileges
Granted to health care professionals to define what categories of patients
can be seen by the professional along with the type of services and
procedures that can be performed within the hospital.
Agency for Health Care Administration (AHCA)
A regulatory agency in Florida created in 1992 under the Health Care
Reform Act of 1992 for the purpose of ensuring that efficient quality health
care services are accessible to all Floridians.
American Academy of Professional Coders (AAPC)
National organization founded for the purpose of elevating medical coding
standards by providing ongoing education, networking opportunities,
certification, and recognition of health insurance billing and coding
professionals.
American Health Information Management Association(AHIMA)
National organization founded for the purpose of setting national standards
in health information management and certification and providing support
to health information management professionals.
American Osteopathic Association (AOA)
An organization established in 1997 for the purpose of advancing the
philosophy and practice of osteopathic medicine.
Centers for Medicare and Medicaid Services (CMS)
Agency under the Department of Health and Human Services that oversees
the federal responsibilities for the Medicare and Medicaid programs.CMS
was formerly known as the Health Care Financing Administration (HCFA).
Civil Monetary Penalties Law (CMPL)
A law passed in 1983 for the purpose of prosecuting cases of Medicare and
Medicaid fraud. Conditions for Participation (COP)Conditions established
for providers to participate in the Medicare program. Medicare’s COP
contains CMS rules and regulations that govern the Medicare program.
Providers of service are required to follow regulations outlined in the COP
implemented under the Code of Federal Regulations, Title 42.
Consolidated Omnibus Budget Reconciliation Act(COBRA)
Legislation passed to prevent in appropriate transfer or discharge of
patients from one facility to another, commonly referred to as
“dumping.”Continuing education units (CEUs)Credits earned by individuals
when they attend an educational function. Organizations generally grant 1
CEU for each hour attended.
Credentialing
The process followed by hospitals and other organizations for evaluating
physicians to determine whether they should be granted admitting
privileges.
Department of Health (DOH)
Agency within each state that is involved in the state’s health care
initiatives, including promoting public health and health safety of all state
residents through disease prevention and ensuring that quality medical
care is provided.
Department of Health and Human Services (DHHS)
Federal department responsible for health issues, including controlling the
rising cost of health care, the health and welfare of various populations,
occupational safety, and income security plans.
Emergency Medical Treatment and Labor Act (EMTALA)
Legislation passed by Congress to ensure public access to emergency
services regardless of ability to pay.
Federal False Claims Act
Legislation passed to prevent overuse of services and uncover fraudulent
activities in the Medicare and Medicaid programs.
Federal Register
The official publication in which federal regulations and legal notices are
published.
Health, Education, and Welfare (HEW)
A governmental agency formed for the purpose of addressing issues related
to health, education, and welfare of the people of the United States.
Health Information Management (HIM)
A hospital department responsible for the organization, maintenance,
production, storage, retention, dissemination, and security of patient
information.
Health Insurance Portability and Accountability Act(HIPAA)
Legislation implemented in phases from 1996 to 2008 to address several
issues: continuity of health insurance, prevention and detection of fraud
and abuse, limited coverage, access to long-term care, simplification of the
administration of health insurance standards for the claims process, and
protection of the privacy of health information.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
A national commission formed to evaluate and accredit health care
organizations based on established standards of quality for operations and
medical services.
Occupational Safety and Health Administration (OSHA)
Agency under the Department of Labor created under the OSHA Act for the
purpose of developing standards and conducting site visits to determine
compliance with safety standards.
Office of the Inspector General (OIG)
A federal agency under the DHHS that is responsible for protecting the
integrity of DHHS programs, such as Medicare and Medicaid.
Patient Self-Determination Act (PDSA)
Legislation passed in 1990 for the purpose of ensuring that individuals are
informed of their rights regarding health care decisions. The act requires
facilities to provide patients with information regarding a living will, durable
power of attorney, and advanced directives.
Professional Standards Review Organization (PSRO)
Organizations that contract with Medicare to conduct reviews to determine
the appropriateness and medical necessity of services provided. PSROs
have full authority to deny reimbursement for health care services provides
to Medicare patients if the services are deemed inappropriate.
Accounts receivable
Outstanding accounts in which money is owed by the patient, insurance
company, or government program.
Acute
Sudden onset of a condition or symptoms.
Admission process
Tasks required to receive a patient in the hospital including obtaining
demographic, insurance, and medical information, and entering the data
into the computer system.
Ancillary services
Supportive services provided by various departments, such as radiology.
Census
Inventory of rooms available in the hospital and the patients assigned to
those rooms.
Clinical
Refers to tasks related to medical practice.
Emergency Department (ED)
An area in the hospital where services are provided to patients presenting
with a condition or illness that requires immediate attention.
Health Information Management (HIM)
Hospital department responsible for the organization, maintenance,
production, storage, retention, dissemination, and security of patient
health information. HIM is sometimes referred to as Medical Records.
Health information system
Computer system designed for hospital patient medical and billing
information. History and physical (H & P)A detailed accounting of the
history, physical examination, and decision making involved regarding the
patient’s condition on admission.
Medical record documentation
Information regarding the patient’s condition, treatment, and progress,
required to support charges submitted to various payers. Documentation is
maintained in a chart, called the medical record.
Outpatient
Services are performed at the hospital and the patient is released from the
hospital the same day.
Professional component
The portion of a procedure that represents the physician’s work in
performing the service, such as the reading and interpretation of a
radiology film.
Technical component
The portion of a procedure that represents the overhead utilized in
performing the service, such as the technician, supplies, materials, and
equipment.
Utilization management (UM)
Focuses on monitoring health care resources utilized in the hospital for the
purpose of determining whether the services are appropriate and
necessary in response to the patient’s condition, thereby ensuring
maximum resource utilization.