Healthcare Concepts and Terminology, Exams of Nursing

Download Healthcare Concepts and Terminology and more Exams Nursing in PDF only on Docsity! CCM EXAM 2024/2025 WITH 100% ACCURATE SOLUTIONS CCM EXAM 2024/2025 WITH 100% ACCURATE SOLUTIONS Case management - Precise Answer ✔✔a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client's health and human services needs. Case Management Characteristics - Precise Answer ✔✔characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Glagow Coma Scale - Precise Answer ✔✔Client assessment tool that measures level of coma in the acute phase of injury it is an objective way of recording the conscious state of a person. Eye opening, Best verbal, best motor. < 8 coma, 13-15 mild injury. Strengths Based Model - Precise Answer ✔✔assesses clients capacities and potential resources as well as problems and current unmet needs. Eliciting capacities and potential resources as well as problems and current unmet needs. Independent Living Model - Precise Answer ✔✔sees a disability as a construct of society Measuring performance: behavioral 'process' - Precise Answer ✔✔ex. self-monitoring of blood sugar Measuring performance: Financial - Precise Answer ✔✔ex. fewer ED visits, ALOS decreased Women's Health and Cancer Rights Act of 1998 - Precise Answer ✔✔1. Part of Omnibus Appropriations Bill. 2. required group health plans to provide coverage for mastectomies and provide certain reconstructive related services following mastectomies. Women's health and cancer rights act coverage - Precise Answer ✔✔1. reconstruction of the breast. 2. surgery and reconstruction of the other breast 3. breast prothesis 4. treatment for physical complications attendant to the mastectomy Women's health and cancer rights act prohibitions - Precise Answer ✔✔Health plans are not allowed to deny anyone coverage for the sole reason of avoiding the requirements of the act AND cannot induce a physician to limit the care that is required under the act by penalizing or limiting reimbursement to the physician. Can states modify HIPAA's portability requirement - Precise Answer ✔✔Yes. HIPAA requirements do not supercede state requirements. Stricter laws prevail. States can 1. shorten the 6 month look back period. 2. shorten 12 month maximum pre-existing condition exclusion period.3. increase the 63 day/significant break in coverage 4. increase 30 day period for newborns, adopted children, children placed in adoption and pregnant women. 5. Expand the prohibitions on conditions and people to whom a pre-existing condition exclusion period may be applied beyond exceptions. 6. reduce additional special enrollment periods. 7. reduce maximum HMO affiliation period to less than 2 months. Break in coverage - Precise Answer ✔✔63 days or longer that a subscriber has been without health insurance coverage (not including waiting periods) Waiting period - Precise Answer ✔✔period of time specified by health insurance contract that occurs between signing up for insurance and the beginning of health insurance coverage. Cannot be counted as creditible coverage time. Individuals can use COBRA from their previous employers for health insurance Establishing waiting period - Precise Answer ✔✔HIPAA does not prohibit plans from establishing a waiting period. But the waiting period and the pre-existing conditions exclusions must start at the same time and run concurrently. Creditable Coverage - Precise Answer ✔✔For the purpose of the Health Insurance Portability and Accountability Act, coverage under virtually any type indivual or group health care plan without a break in coverage of 63 days or more. Cannot be taken into account when determining a significant break in coverage. Only coverage after the 63 day break will be counted. Any coverage before the 63 day break will not be considered. COBRA - Precise Answer ✔✔Consolidated Omnibus Budget Reconciliation Act; law to provide terminated employees or those who lose insurance coverage because of reduced work to be able to buy group insurance for themselves and their families for a limited amount of time. Certification of creditable coverage - Precise Answer ✔✔Documentation that is provided automatically by the plan or issuer when the individual loses coverage or becomes entitled to elect COBRA continuation coverage and when an individual's COBRA continuation covearage ceases ; Be provided if requested before loss of coverage or within 24 months of loss of coverage. May be provided through use of model certificate Nondiscrimination requirements - Precise Answer ✔✔Inividuals cannot be excluded from coverage under the terms of the plan based on specified factors related to health status. Health plans cannot establish rules of eligibility based on healht status related factors" such as health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability or disablity. Insurer cannot drop a patient from coverage because it knows that the patient will require a liver transplant next year. Cannot charge more for premiums based on health status. Security of health information and electronic signature standards - Precise Answer ✔✔provides a uniform level of protection of all health information that is housed or transmitted electronically. pertains to the individual. group health plans and health insurance issuers that choose to include MH/SUD benefits in their benefit packages. However, the Affordable Care Act builds on MHPAEA and requires coverage of mental health and substance use disorder services as one of ten EHB categories Exceptions to MHPAEA 2008 - Precise Answer ✔✔Except as noted below, MHPAEA requirements do not apply to: Non-Federal governmental plans that have 100 or fewer employees; Small private employers that have 50 or fewer employees; Group health plans and health insurance issuers that are exempt from MHPAEA based on their increased cost (except as noted below). Plans and issuers that make changes to comply with MHPAEA and incur an increased cost of at least 2% in the first year that MHPAEA applies to the plan or coverage or at least one percent in any subsequent plan year may claim an exemption from MHPAEA based on their increased cost. If such a cost is incurred, the plan or coverage is exempt from MHPAEA requirements for the plan or policy year following the year the cost was incurred. These exemptions last one year. After that, the plan or coverage is required to comply again; however, if the plan or coverage incurs an increased cost of at least 1% in that plan or policy year, the plan or coverage could claim the exemption for the following plan or policy year; Large, self-funded non-Federal governmental employers that opt-out of the requirements of MHPAEA. hard savings - Precise Answer ✔✔Examples of "hard" savings are directly linked to Case Management. Examples would be reduction in payer denials or decrease in avoidable days. soft savings - Precise Answer ✔✔Examples of "soft" savings are indirectly linked to Case Management such as lower readmission rates or lower post-op complication rates. These can be converted into dollars. 1987 Nursing Home Reform Act - Precise Answer ✔✔The basic objective of the Nursing Home Reform Act is to ensure that residents of nursing homes receive quality care that will result in their achieving or maintaining their "highest practicable" physical, mental, and psychosocial well-being. To secure quality care in nursing homes, the Nursing Home Reform Act requires the provision of certain services to each resident and establishes a Residents' Bill of Rights. CARF - Precise Answer ✔✔Commission on Accreditation of Rehabilitation Facilities Wickline v. The State of California - Precise Answer ✔✔the point of this litigation is that a physician/surgeon is still responsible for negligently discharging a patient even if the financial benefits related to the hospital stay have been exhausted. Wickline also seems to suggest that a physician can be negligent for not acting more aggressively as a patient's advocate with third-party payers ADA reasonable accommodations - Precise Answer ✔✔-Making existing facilities used by employees readily accessible to and usable by persons with disabilities. -Job restructuring, modifying work schedules, reassignment to a vacant position; -Acquiring or modifying equipment or devices, adjusting or modifying examinations, training materials, or policies, and providing qualified readers or interpreters. The Individuals with Disabilities Education Act (IDEA) - Precise Answer ✔✔Public Law 94-142 - a law ensuring services to children with disabilities throughout the nation. IDEA governs how states and public agencies provide early intervention, special education and related services to more than 6.5 million eligible infants, toddlers, children and youth with disabilities. Abandonment - Precise Answer ✔✔termination of a professional relationship without reasonable notice to the patient and without an opportunity for the patient to acquire alternative care or services thereby resulting in injury to the patient. Agency - Precise Answer ✔✔relationship between two or more persons by which one consents that the other (the agent) shall act on his or her behalf. Legal obligations to: 1. use care and skill 2. act in good faith 3. staying within the limits of authority 4. obeying the principal and carrying out all reasonable instructions 5. advancing the interests of the principals 6. acting solely on the principal's benefit. Implies a conflict of interest between the case manager and the employer and the professional duties to the patient. Damages - Precise Answer ✔✔Monetary compensation awarded for acts of tort for both tangible (medical expenses, loss wages) and intangible (pain and suffering) Discovery - Precise Answer ✔✔Ascertainment of what is not previously known. All evidence that is material and necessary in the prosecution or defense of action is produced and exchanged by the parties or as ordered by the court. Event (incident) - Precise Answer ✔✔a situation that is reported by the insured provider to his or her insurance company which may lead to a formal claim or malpractice suit. Examination before trial - Precise Answer ✔✔obtaining information by sworn oral testimony False Claims Act - Precise Answer ✔✔Federal penalties for those who knowingly present false claim or against the government. It is illegal to present a false or fraudulent claim upon or against the US. HOld harmless provision - Precise Answer ✔✔Contract between insurer and provider of services that specifies that the providers assumes liability for covered services even if the managed care organization becomes insolvent. Inherent risk - Precise Answer ✔✔a complication that is commonly associated with a treatment and is not due to negiligence of the provider of the treatment. Invasion of privacy - Precise Answer ✔✔wrongful intrusion into one's private activities which would cause harm to the patient Liability - Precise Answer ✔✔debt, responsibility, obligation Liability, joint - Precise Answer ✔✔Obligation as a group or as a whole and all its individual members. A party that has been harmed can sue the group as a whole or by its individuals but the suer cannot get more compensation by suing individually than by suing as a whole. Liability limits - Precise Answer ✔✔Restriction or upper boundary on the amount of money on insurance company will pay in order to satisfy a claim against an insured. A calim for a sum beond this limit is not protected bt teh insurance policy and is that the responsibility of the defendant Liable - Precise Answer ✔✔bound by law or fairness responsible and accountable Malpractice - Precise Answer ✔✔Act of negligence, 1. negligence: a deviation from the approved and accepted standards of care. 2. injury which damage is to the patient as result of the negligence. Most favored nation Clause - Precise Answer ✔✔provider is obligated to render products or services to the purchaser at the same rate as his most favored customer Negligence - Precise Answer ✔✔Failure to use the degree of care . Ommision and commission. Negligent credentialing - Precise Answer ✔✔When a organization does not exercise care when investigating a provider's credentials. Example when an organization selects a provider who negligently injures a patient, has a history of doing so or is found not to have the appropriate training , experience, skill or licensure to care for the patient. Negligent Referral - Precise Answer ✔✔Referring a patient to a provider who does not posses the right credentials, skills, licensure or who has been known to be negligent in the past. Ombudsman - Precise Answer ✔✔a person who investigates customer complaints against their employer. Ostensible agency - Precise Answer ✔✔A principal gives a third party reason to believe another person is his/her agent; other person is unaware of the appointment. In these cases the "principal" is responsible for the acts of the agent. Principal gives apparent authority to the agent and will be liable for his acts -A predetermined base payment for each 60-day episode of care is adjusted according to patient's HHRG -No limit to number of 60-day episodes -Payment is adjusted if patient's condition significantly changes DRG - Precise Answer ✔✔Diagnosis-related group Managed care A unit of classifying Pts by diagnosis, average length of hospital stay, and therapy received; the result is used to determine how much money health care providers will be given to cover future procedures and services, primarily for inpatient care. -Primary diagnosis determines assignment to one of 535 DRGs -The DRG payment rate is adjusted based on age, sex, secondary diagnosis and major procedures performed. DRG payment is per stay. -Additional payment (outlier) made only if length of stay far exceeds the norm RUG - Precise Answer ✔✔-Fifty-eight groups -Each beneficiary assigned a per diem payment based on Minimum Data Set (MDS) comprehensive assessment -A specified minimum number of minutes per week is established for each rehabilitation RUG based on MDS score and rehabilitation team estimates SNF - Precise Answer ✔✔A facility that provides 24-hour medical care provided by registered nurses, licensed vocational nurses as well as nurses aides. Licensed Physical Therapists, Occupational Therapists, and Speech Therapists are also available. Typically for patients who require services that can only be given by a licensed provider such as IVABX, IV pain management, wound care, g-tube feeding or physical rehabilitation needed 1-3 hours a day on a daily basis. An M.D. will usually evaluate pt. within the first 72 hours and then monthly thereafter. In order for Medicare to cover (and Medicare only) pt. must have a three-day qualifying stay in the acute setting (think midnights). As long as pt. has a skilled need and a qualifying stay Medicare will cover the first 20 days at 100 percent, day 21-100 is $119.00 a day which the pt. or the pt's secondary insurance is responsible for. Most SNFs also have a custodial side for pts. whose needs can no longer be met at home or at a lower level of care. Other than MediCal, Medicare and most private insurances, (with the exception of long term care insurance) will NOT cover custodial care in a SNF. Subacute Care Unit - Precise Answer ✔✔For patients who no longer require the intensive procedures of an acute care Hospital, but do require the diagnostic or invasive procedures of an inpatient healthcare facility. Patients who are transferred to a sub acute facility may have a trach and require frequent suctioning. Individuals may also need to be weaned from a ventilator. Patients residing in this environment generally need between four and seven hours of skilled nursing/respiratory care each day. Medicare does not recognize the sub acute level of care and will only reimburse on a SNF level, so the determination of acceptance is usually made on a case by case basis by the individual facility. MediCal does recognize the Sub acute level, however, the pt. must have a trach AND another needs i.e. feeding tube, wound care or TPN. Only a few sub cutes have dialysis available on site. LTAC - Precise Answer ✔✔Structured and programmed for medically complex and often catastrophically ill patients. Patients are admitted for acute care, with lengths of stay that average 25-30 days; typical of medically complex patients. The intensity of service will normally exceed the care needs that can be met by a sub-acute or skilled nursing facility. An LTAC will generally be able to provide such services as vent weaning and respiratory care, complicated wound care, TPN; Surgeries such as Tracheotomies, wound debridment, skin flaps, an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. Disability Case Mangemtn - Precise Answer ✔✔A process of managing occupational and no-occupational diseases with the aim of returning the disabled employee to a productive work schedule and employment. Disability Income Insurance - Precise Answer ✔✔A form of health insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury or disease Handicap - Precise Answer ✔✔The functional disadvantage and limitation of potentials based on a physical or mental impairment or disability that substantially limits or prevents the fulfillment of one or more major life actives, otherwise considered normal for that individual based on age, sex and social/cultural factors, such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, working, etc. Handicap is a classification of role reduction resulting from circumstances that place an impaired or disabled person at a disadvantage compared to other persons. Handicapped - Precise Answer ✔✔Refers to the disadvantage of an individual with a physical or mental impairment resulting in a handicap. Learning Disability - Precise Answer ✔✔A lack of achievement or ability in a specific learning area(s) within the range of achievement of individuals with comparable mental ability. Most definitions emphasize a basic disorder in psychological processes involved in understanding and using language, spoken, or written SSDI - Precise Answer ✔✔Social Security Disability Income: Federal benefit program sponsored by the Social Security Administration. Primary factor: disability and/or benefits received from deceased or disabled parent. Benefit depends upon money contributed to the Social Security program either by the individual involved and/or the parent involved. Total Disability - Precise Answer ✔✔An illness or injury that prevents an insured person from continuously performing every duty pertaining to his/her occupation or engaging in any other type of work Case Management - Precise Answer ✔✔A collaborative process, which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes. Key elements to Case Management (9) (a p cs ds l a me er po) - Precise Answer ✔✔• Assessment • Planning • Coordinate Services • Deliver Services • Linkage • Advocate • Monitoring & Evaluating • Efficient use of Resources • Promote Positive Outcome Assessment - Precise Answer ✔✔Getting the background info Planning - Precise Answer ✔✔Looking ahead Coordinate Service - Precise Answer ✔✔Holistic view of the client, many services must be coordinated Deliver Service - Precise Answer ✔✔CMs often deliver services themselves Linkage - Precise Answer ✔✔Relates to service coordination. Makes sure the client is connected to resources out there Advocacy - Precise Answer ✔✔CM have the responsibility for being the voice of the client Monitoring and evaluating - Precise Answer ✔✔• If providing management, you must assess and assure the delivery of the services are on target • What's the impact of the services (b) rehab facilities became more persuasive (more government money) (c) public mental health deinstitutionalization (d) passage of Rehab Act of 73, beginning of private rehab Physiatry - Precise Answer ✔✔A branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities (AKA: rehabilitation medicine) Key Case Manager competencies (Part 1) - Precise Answer ✔✔• Relationship building and counseling • Assessment/monitoring/evaluating • Planning • Decision making Key Case Manager competencies (Part 2) - Precise Answer ✔✔• Advocacy • Conflict resolution • Payment sources (how, rules and regs, code usage) • Caseload management • Community resources (making connections, who provides) Case Manager Credentials - Precise Answer ✔✔• Certification - CCM (Certified Case Manager) - CDMS (Certified Disability Management Specialist) - LCP (Life Care Planning) • Certification require a base in one's own field first • Adds to credibility Rehab Counselor vs. Social Worker - Precise Answer ✔✔Better understanding of a disability, or VC rehab Rehab Counselor vs. Nursing - Precise Answer ✔✔Nurses better on medical knowledge Case Managers vs. Counseling - Precise Answer ✔✔Counselors more specific service provided ; a CM is more general orientated Case Managers Setting (a wide variety) 10 total (Part 1) - Precise Answer ✔✔• Secondary school (help client move on to higher ed) • University (DRS office for post-secondary) • Corporate (work stations in order, WC claims, health benefits) • Public VR (return client to work quickly) • Private VR (return client to work, take your time) Case Managers Setting (a wide variety) 10 total (Part 2) - Precise Answer ✔✔• Community (MH, substance abuse, VR) • Public Health (HIV resources) • Hospital (community support post release) • Insurance (Utilization & physician work review) • Forensic (Testifying) Mental Health Case Manager (Part 1) 5 total - Precise Answer ✔✔• Residential • Pre-discharge planning (post release needs reapply) • Day support • Medication management Mental Health Case Manager (Part2) 5 total - Precise Answer ✔✔• Intensive Case Manager - (serve most needy people ; take the team to the client rather than the client coming to the community because they could not do so) • Homelessness Case Manager - Search for mentally ill homeless people - Blend in & build relationships w/ the homeless 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression morisky medication adherence questionaire - Precise Answer ✔✔Do you sometimes forget to take your medicine? People sometimes miss taking their medicines for reasons other than forgetting. Thinking over the past 2 weeks, were there any days when you did not take your medicine? Have you ever cut back or stopped taking your medicine without telling your doctor because you felt worse when you took it? When you travel or leave home, do you sometimes forget to bring along your medicine? Did you take all your medicines yesterday? When you feel like your symptoms are under control, do you sometimes stop taking your medicine? Taking medicine every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your treatment plan? How often do you have difficulty remembering to take all your medicine? __ A. Never/rarely __ B. Once in a while __ C. Sometimes __ D. Usually __ E. All the time Tools for child development assessment - Precise Answer ✔✔HELP, Bayley and Denver Tools for brain injury - Precise Answer ✔✔Glasgow Coma Scale Rancho Los Amigos Braden scale - Precise Answer ✔✔pressure sore risk MDS for SNF - Precise Answer ✔✔Categories of MDS (Minimum Data Set) 1) Cognitive patterns 2) Communication and hearing patterns 3) Vision patterns 4) Physical functioning and structural problems 5) Continence 6) Psychosocial well-being 7) Mood and behavior patterns 8) Activity pursuit patterns 9) Disease diagnoses 10) Other health conditions 11) Oral/nutritional status 12) Oral/dental status 13) Skin condition 14) Medication use 15) Treatments and procedures Short form-36 - Precise Answer ✔✔Quality of life perception tool The RAND 36-Item Health Survey (Version 1.0) laps eight concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, emotional well-being, social functioning, energy/fatigue, and general health perceptions. It also includes a single item that provides an indication of perceived change in health. Subacute - Precise Answer ✔✔a broad range of medical and rehabilitative services and settings that provide care to post-acute patients Acute Care - Precise Answer ✔✔Acute care is a care setting where a patient is treated for a brief but severe episode of illness. The term is generally associated with care rendered in an emergency department, ambulatory care clinic, or other short-term stay facility. The most common acute care setting is a traditional hospital, which typically offers both inpatient and outpatient care in specialty areas including but not limited to emergency care, an alternative setting. Such care settings might be in a hospital or skilled nursing facility or a free-standing facility and are licensed and certified and primarily promote special rehabilitative health care services rather than general medical and surgical services. Examples of conditions requiring acute inpatient rehabilitation include, but are not limited to, individuals with significant functional disabilities associated with stroke, spinal cord injuries, acquired brain injuries, major trauma and burns. The goal is the restoration of a disabled person to self-sufficiency or maximal possible functional independence. An inpatient rehabilitation program utilizes an inter-disciplinary coordinated team approach that typically involves a minimum of three (3) hours of rehabilitation services daily. These services may include physical therapy, occupational therapy, speech therapy, cognitive therapy, respiratory therapy, psychology services, prosthetic/orthotic services, or a combination thereof. FIM (Functional Independence Measure) - Precise Answer ✔✔is the most widely accepted functional assessment measure in use in the rehabilitation community. The FIM(TM) is an 18-item ordinal scale, used with all diagnoses within a rehabilitation population. It is viewed as most useful for assessment of progress during inpatient rehabilitation. What is Case management - Precise Answer ✔✔it is a cross- disciplinary and interdependent specialty practice. Case management is - Precise Answer ✔✔a means for improving clients' health and promoting wellness and autonomy through advocacy, communication, education, identification of service resources, and facilitation of service. Case management is guided by the principles of autonomy, beneficence, nonmaleficence, and justice primary function of case managers - Precise Answer ✔✔to advocate for clients/support systems Case managers' first duty - Precise Answer ✔✔coordinating care that is safe, timely, effective, efficient, equitable, and client-centered. Case Management Process - Precise Answer ✔✔Screening, Assessing, Stratifying Risk, Planning, Implementing (Care Coordination), Following-Up, Transitioning (Transitional Care), Communicating Post Transition, and Evaluating Case Management Plan of Care - Precise Answer ✔✔Describes: The client's problems, needs, and desires, as determined from the findings of the client's assessment. The strategies, such as treatments and interventions, to be instituted to address the client's problems and needs. The measurable goals - including specific outcomes - to be achieved to demonstrate resolution of the client's problems and needs, the time frame(s) for achieving them, the resources available and to be used to realize the outcomes, and the desires/motivation of the client that may have an impact on the plan Level of Care - Precise Answer ✔✔The intensity and effort of health and human services and care activities required to diagnose, treat, preserve, or maintain clients' health. Level of care may vary from least to most complex, least to most intense, or prevention and wellness to acute care and services The High Level Case Management Process - Precise Answer ✔✔Case managers navigate the phases of the process with careful consideration of the client's cultural beliefs, interests, wishes, needs, and values. By following the steps, they help clients/support systems to: Evaluate and understand the care options available to them Determine what is best to meet their needs Institute action to achieve their goals and meet their interests/expectations At the same time, case managers apply: Relevant state and federal laws. Ethical principles and standards such as the CCMC's Code of Professional Conduct for Case Managers with Standards, Rules, Procedures, and Penalties (CCMC, 2009), which applies to persons holding the CCM® credential. Accreditation and regulatory standards. Standards of care and practice such as the CMSA Standards of Practice for Case Management (CMSA, 2010) The Case Management Process: Stratifying Risk (2) - Precise Answer ✔✔When stratifying a client's risk, a case manager completes a health risk assessment and biomedical screening based on specific risk factors. These risk factors include the client's blood pressure, substance use, alcohol use, tobacco use, nutrition habits, exercise habits, blood sugar level, lipids profile/cholesterol, emotional health, physical health, access to care and utilization of healthcare services (e.g., emergency department visits or hospitalizations), psychosocial, financial (e.g., limited income, no insurance, underinsurance), and other factors, depending on the risk assessment tool/model applied. The Case Management Process: Planning - Precise Answer ✔✔Planning phase establishes specific objectives, goals (short- and long-term), and actions (treatments and services) necessary to meet a client's needs as identified during the Assessing phase. During the Planning phase, the case manager develops a case management plan of care that considers inputs and approvals of the client and the client's healthcare providers. The plan is action- oriented, time-specific, and multidisciplinary in nature. It addresses the client's self-care management needs and care across the continuum, especially services needed after a current episode of care. In addition, the case management plan of care identifies outcomes that are measurable and achievable within a manageable time frame and that apply evidenced-based standards and care guidelines. Planning is completed after authorization for the health and human services to be rendered has been given by the payor source and after the services and resources needed have been identified. The Case Management Process: Implementing: Care Coordination - Precise Answer ✔✔The Implementing phase centers on the execution of the specific case management activities and interventions that are necessary for accomplishing the goals set forth in a client's case management plan of care. This role is commonly known as care coordination. During this phase, the case manager organizes, secures, integrates, and modifies (as needed) the health and human services and resources necessary to meet the client's needs and interests. The case manager shares information on an ongoing basis with the client and the client's support system, the healthcare providers/clinicians, the insurance company/payor, and community-based agencies. The Case Management Process: Following-up - Precise Answer ✔✔The Following-Up phase focuses on the review, evaluation, monitoring, and reassessment of a client's health condition, needs, ability for self-care, knowledge of condition and treatment regimen, and outcomes of the implemented treatments and interventions. The case manager's primary objective is to evaluate the appropriateness and effectiveness of the case management plan and its effect on the client's health condition and outcomes. During this phase, the case manager gathers sufficient information from all relevant sources; shares information with the client, healthcare providers, and others as appropriate; and documents in the client's health record the findings, modifications made to the case management plan, and recommendations for care. These activities are repeated at frequent intervals and as needed. Following-up may indicate the need for a minor modification or a complete change in the case management plan of care. The Case Management Process: Transitioning: Transitional Care - Precise Answer ✔✔The Transitioning phase focuses on moving a client across the health and human services continuum or levels of care depending on the client's health condition and the needed services/resources. During this phase, the case manager prepares the client and the client's support system either for discharge from the current care setting/facility to home or for transfer to another healthcare facility or a community-based clinician for further care. These activities are commonly known today as transitional care or transitions of care. In order to maintain continuity of care, this phase's activities entail the complete execution of the client's transition through communication with key individuals (including sharing of necessary information) at the next level of care or setting, the client and client's support system, and members of the healthcare team. Additionally, the case manager educates the client about post- transition care and needed follow-up, summarizes what happened during an episode of care, secures durable medical equipment (e.g., glucose meter, scale, walker) and transportation services (if needed), Psychiatric Disablity - Precise Answer ✔✔a silent comborid condition can affect a patients physical health and quality of life Dual Diagnosis - Precise Answer ✔✔Substance abuse and mental health combined diagnosis polypharmacy - Precise Answer ✔✔unintended duplication of drugs that usually results when patients see multiple physicians or frequent numerous pharmacies using homeopathic, supplemental,or OTC or herbal medcicnes also put individuals at risk for what? unintentional polypharmacy - Precise Answer ✔✔seeking competitive drug pricing or when useing various pharmacies with locations near work, home, social events. See it in older adults who visist mutliple physicians Managed Care OrganIzation ( MCO) - Precise Answer ✔✔what can help prevent polypharmacy intentional polypharmacy - Precise Answer ✔✔addicted to drugs is an example of IT software systems - Precise Answer ✔✔IT software now can notify ordering MD about potential abuses ie polypharmacy. Can interface with disease managment where pharmacy daa and claims data are used to stratify health patterns and health profiles of patients Blinking light for MD's - Precise Answer ✔✔taking 5 or more medications using different pharmacies to fill scripts chronic pain - Precise Answer ✔✔people you have chronic pain develop a dependency fro a pain med regimen that allows them to tolerat their daily living activites and lead a fairly normal life. they do get the label of addicted drug-seeking patients BASIS 32 - Precise Answer ✔✔a common and effective assessment tool for the patient suspected of having substance abuse/mental health Identification of patient - Precise Answer ✔✔First step in CM process utilization management - Precise Answer ✔✔computer software helps ID cases for CM flag the ones that exceed a certain amount of money or hospitalization is found in which department consultation - Precise Answer ✔✔the act of conferring with another individual for the purpose of gaining an opinion or advice is known as physician - Precise Answer ✔✔keep decision maker autocratic - Precise Answer ✔✔sole responsbility legally and ethically for physicians can be Medication Thearpy Managment - Precise Answer ✔✔used in Medicare and Medicaid part B collaboration/communication - Precise Answer ✔✔The glue that binds all the process of Case management together frontal lobe injury - Precise Answer ✔✔problems with activities involving planning, organizing and problem solving poor attention personality changes occipital lobe - Precise Answer ✔✔visual problems Temporal lobe - Precise Answer ✔✔short term memory loss inablity to process information smell and sound deficienies Left parietal lobe - Precise Answer ✔✔written spoken language problem Phase 1 - Precise Answer ✔✔first times in humans Phase 2 - Precise Answer ✔✔exploratoy Phase 3 - Precise Answer ✔✔confirmatory phase 4 - Precise Answer ✔✔post marketing P-value porpability - Precise Answer ✔✔0.0-1.0 < 0.05 statistically significant Single Blind - Precise Answer ✔✔investigator knows treamtent paitent is receiveing open label - Precise Answer ✔✔both the patient and investigator know the treatment patient is receiving Double blind - Precise Answer ✔✔neither investigator nor pt know treament patient is receiving Compartive effectiveness - Precise Answer ✔✔a rigorous evaluation of the impact of different opitons that are available for treating a given medical condition for apraricualr set of patients Comparive effectiveness research - Precise Answer ✔✔to assist consumers and clinicians, purchasers, and policy makers to make informed decisions that will imporve health care at both the individual and population level. This helps CM to appropriatley influncene patient decisions ... - Precise Answer ✔✔Case managers need to understand and embarace evidence before teaching others, get in the habit of reviewing pertinent evidence in the literature. Accountable Care Organization - Precise Answer ✔✔an entity charged with the bundling of care services of hospitals, physicians, other entities and care providers who are delivering services during an episode of care. Providers/organizations share in the cost savings achieved as a result of coordination Adjudication - Precise Answer ✔✔the process of completing all validity, process, and file edits necessary to prepare a claim for final payment or denial, or the processing of a claim through a series of edits to determine proper payment. ADL - Precise Answer ✔✔an acronym for " activites of daily living" Adminstrative Costs - Precise Answer ✔✔The Costs assumed by a managed care plan for administrative servies, such as claims processing, billing, and overhead costs Adverse Selection - Precise Answer ✔✔The risk of enrolling members who are sicker and will require more medical services than initially assumed and who will utilize more expensive servies more frequently Affordabale care Act - Precise Answer ✔✔another name for Patient Protection and Affordable care Act Aftercare - Precise Answer ✔✔services adminsistered after hopsitalization or rehabilitation that are individualized fro each patient's needs Age/Sex Rating - Precise Answer ✔✔structuring premium payments based on members age and gender AHA - Precise Answer ✔✔an acronym for American Hospital Association AIDS - Precise Answer ✔✔an acronym for Acquired Immunodeficiency Syndrome Alcoholism - Precise Answer ✔✔A mental and/or physical depenence on alcohol due to chronic and habitual use Alcoholism or Drug addiction treatment facility - Precise Answer ✔✔a legally operated, free standing facility or clinic, or part of a Assignment - Precise Answer ✔✔An arrangement in which the provider submits the claim on behalf of hte aptient and is reimbursed direclty by the patients plan. Authoriation ( also called Pre-authoriation or Pre-certification - Precise Answer ✔✔In managed care it r3efers to the approval of care, such as a hospitalization, certain diagnositce test, or even non covered medications. Preauthoiration may be required before admisttion takes plan or care is given by non-managed care providers AWP - Precise Answer ✔✔When referring to medications, it is an acronym for " average wholesale price". It is the pulished average cost of a drug product by the pharmacy to the wholesaler. It is psecific to drug strength, dosage from ( capsule, tablet solution, vial) package size, and manufacturer or labeler. When it is not referring to medications, this abbreviation also stands for " any willing provider " Statues requiring a provider network to accept any provider who meets the network's usual selection criteria Behavioral Health Care - Precise Answer ✔✔Treatment of menatla health and/or substanc abuse disorders Beneficiary - Precise Answer ✔✔any peson or persons named by a policyholder to receive the policy holder's insurance benefits or coverage Benefit Level - Precise Answer ✔✔The limit or degree of services a person is entitled to receive based on his or her contract with health plan or insurer Benefit Package - Precise Answer ✔✔th services an insurer, goverment agency,health plan, or employer offers under the terms of a contract Cafeteria Plan - Precise Answer ✔✔a corporate benefits plan under which all employees are permitted to choose among two or more benefits that consist of cash and certain qualifed benefits. Cafteteria plans are also called flexible benefit plans or flex plans Calendar year - Precise Answer ✔✔The inclusive period of time from January 1 of any year through December 31 of the same year. This is most often used in connection with deductible amount provisions of major medical plans providng benefits for expenses incurred within the calendar year. CapM - Precise Answer ✔✔the contract maximum, which is the limit or " cap that the insurance company will pay out for a given individual. Capitation - Precise Answer ✔✔A method of payment used in manged care as per-member monthly payment to a provider that covers contracted servies and is paid in advance of its delivery. In essence, a provider agrees to provide specified services to health plan members usually in a health maintenance organization( HMO) for this fixed, predetermine payment for a specified length of time (usually a year) regardless of how many times the member uses the service. The rate can be fixed for all members or it can be adjusted for the age and sex of the member, based on actuarial projections of medical utilization Carrier - Precise Answer ✔✔The insurance company which holds the financial risk and is responsible for adminstering the plan benefits Certificate of Coveage - Precise Answer ✔✔a descripiton of the benefits included in a carrier's plan. The certificate of coverage is required by state laws and respresents the coverage provided under the contract issued to the employer CHAMPUS - Precise Answer ✔✔An acronym of Civilian health and Medical Program of the Unifored Services. Is the federal medical beneifts reimbursment program for dependents of military personnel, military retirees, and others. It is now known as TRICARE Charge - Precise Answer ✔✔A charge is deemed to incurred on the date on which the treatment, care services or supply is made or given. If it is not shown otherwise and a single charge is made for a series of treatments, servies, supplies, or care sessions each will be deemed to bear a pro rata share of the charge filled or diagnositc test. Today, nearly all health plans have implemented multi-tiered co-pays particualry for pharmacy benefits. In managed care plans, the member pays the copayment while checkin in for his or her appointment. Services subject to a copayment are not subject to deductible and coinusrance. For example, a prescripiton for a generic drug may be associated with only a $ 7.50 copay; a prescripition for a preferred brand name drug my have a $ 15 co-pay and a co-pay for a nonpreferred brand name drug may be $50 Covered Charges - Precise Answer ✔✔Charges for medical care and supplies for which the insurance plan will pay CPT code - Precise Answer ✔✔a unique set of 5 digit identifying numerical code that accompanies a list of medical services performed by physicians and other health care providers. CPT codes are developed and maintained by the American Medical Association. It has become the industry coding standard for reporting. CPT Modifers - Precise Answer ✔✔Additional codes that indicate that a service was altered in some way from the stated CPT description without actually changing the basic definition of the service. Modifiers can indicate: a service or procedure that has both a professional and a technical component; a service or procedure that was preformed by more than one physician; that only part of a service was performed; that an adjunctive service was performed; that a bilateral procedure was preformed; that service or procedure was provided more than once; an unusual event occurred, or a procedure or service was altered in some way. A compete listing of all modifiers used in CPT coding is located in an appendix of CPT CQI - Precise Answer ✔✔an acronym for " continous quality improvment" Credentialing - Precise Answer ✔✔The reviewing of medical degrees, licensure, malpractice and any disciplinary record of medical poroviders to determine if they should be entitled to privileges at a hospital, health system or to contract with a managed cae organIzation. Credentialing is usually preformd for panel and quality assurance purposes Critical Care - Precise Answer ✔✔THE CARE OF CRITCALLY ILL PATIENTS IN A VARIETY OF MEDICAL EMERGENCIES THAT REQUIRES THE CONSTANT ATTENDANCE BY THE PHYSICIAN( CARDIAC ARREST, SHOCK, BLEEDING, RESPIRATORY FAILURE, POSTOPERATIVE COMPLICATIONS, OR CRITICALLY ILL NEONATE D/C - Precise Answer ✔✔An abbreviation used for either " discharge or discontinue Days per Thousand - Precise Answer ✔✔a standard unit of measurement of utiliztion determined by calculating the number of hospital days used in a year of each thousand covered lives Deductible - Precise Answer ✔✔A fixed amount of helath care dollars of which a person must pay 100% before his or her health benefits begin. Most indemnity plans feature a $200 or $1200 deductible, and then pay up to a defined percentage of money spent for covered services above this level Dependent - Precise Answer ✔✔An individual who receives health insurance through a spouse, parent , domestic partner, or other family member Diagnosis - Precise Answer ✔✔The identification of a condition, disease, or syndorme and its implications, via examination Disallowance - Precise Answer ✔✔a denial by a health care payer for portions of the claimed amount. Examples could include coordination of benefits, services that are not covered, or amounts over the fee maximum Discharge plan - Precise Answer ✔✔a plan submitted by a provider to the case manager as part of the treatment arrangement that details follow-up care after discharge Disenrollment - Precise Answer ✔✔The procedure of dismissing individuals or groups from their enrollment with a health care carrier Emergicenter - Precise Answer ✔✔A health care facility, the primary purpose of which is the provision of immediate, short-term medical care for urgent medical conditions Employee Contribution - Precise Answer ✔✔The portion of the insurance premium paid by the employee Enrollee - Precise Answer ✔✔The person who subscribes to a specific health plan EOB - Precise Answer ✔✔an acronym for " explanation of benefits" It is a statement mailed to the health plan or insured member( and sometimes provider) explaining claim and payment Episode of Care - Precise Answer ✔✔All treatments rendered in a specifed time frame for a specific disease EPO - Precise Answer ✔✔An abbreviation for Exclusive Provider OrganIzation, An EPO is a form of preferred provider organization of PPO, in which patients must visit a caregiver that is on its panel of providers. If a visit to an outside provider is made, the EPO will offer limited or no coverage for the office/hospital visit. ERISA - Precise Answer ✔✔An acronym for Employee Retirement Income Security Act. This act has several provisions protecting both the payer and member, including requiring that payers send the member an EOB when a claim is denied Exclusions - Precise Answer ✔✔Also referred to as exceptions; refers to services or drugs not covered by the health plan/insurance Experimental drugs - Precise Answer ✔✔Drugs that are still being investigated. They are not yet approved by the Food and Drug administration ( FDA) for any use. Additionally, there is not enough accumulated scientific data to establish medically appropriate use of the drug for treatment of a disease. However, the FDA has established programs to allow patients with an immediately life- threatening disease " early access" to new treatments. Since patients who have exhausted standard therapeutic options may be willing to accept additional risks and potentially dangerous side effects from drug products still under study, these programs allow patients access to invesigational drugs. Experimental/investigational drugs are usally excluded benefits in managed care organizations and therefore are not covered for enrollees. Extended care Facility - Precise Answer ✔✔A nursing home or other long-term setting that offers skilled, intermediate, or cusodial care. Extension of benefits - Precise Answer ✔✔A component of some health care insurance ploicies that allows medical coverage to continue past the termination date of the policy for employees not activley at work FDA - Precise Answer ✔✔Anacronym for the United States ( US) Food and Drug Adminstration Fee-for-services( FFS) - Precise Answer ✔✔traditional provider reimbursement in which the physician is paid according to the service performed. this is the reimbursment system used by conventional indemnity insurers Fee schedule - Precise Answer ✔✔The maximum fees a plan will pay for servies, primarly listed by CPT code Fee-for-services( FFS) - Precise Answer ✔✔this is the reimbursment system used by conventional indemnity insurers Formulary - Precise Answer ✔✔A specific list of drugs that are covered within a given health plan ( MCO) , health system or hospital which may be used in patients that are being cared for in that particular setting. The list is continually updated as new information about medications becomes available. When drugs are reviewed for formulary inclusion, efficacy and safety are considered first, follwed by cost. If, however, the safety and efficacy are the same for agents being reviewed, cost may be considered first. the formulary usually includes other information on related products and information, representing the clinical judgement of physicians, pharmacists, and other experts in the diagnosis and/or treatment of disease and health promotion. The most common types of formularies are closed and open formulary. They may also be referred to as a preferred drug list freestanding Outpatient Surgical Center - Precise Answer ✔✔A healthcare facility, that is physically separate from a hospital, which by carriers nationally and are updated annually by CMS. Level II/Local modiferes are assigned by individual Medicare carriers and are distributed to physicians and suppliers through carrier newsletters. The carrier may change, add or delete these local modifiers as needed. Health Care and Education Reconciliation Act - Precise Answer ✔✔Signed into law on March 30,2010. Commonly referred to as " Health care reform" when taken in conjunction with the Patient Protection and Affordable care Act of 2010. Health Care Reform - Precise Answer ✔✔Common term for the collective changes to the health care industry as a result of the Patient Protection and affordable care Act of 2010 in conjunction with the Health care and Education Reconciliation Act of 2010 Health Maintenance Organization HMO - Precise Answer ✔✔A form of health insurance in which its members pre-pay a premium for healthservices, which generally includes inpatient and ambulatory care. For the patient, it means reduced out-of-pocket costs( no deductible), no paperwork( insurance forms, and only a small co-payment for each office visit to cover the paperwork handled by the HMO Staff Model - Precise Answer ✔✔Employs providers directly and directs care through clinics, where everything is in one place ( centralized). Physicians are more like employees for the HMO in this setting rather than employees of a group or private practice. Group Model - Precise Answer ✔✔Contracts with a closed panel of physicians which are paid a fixed amount per patient to provide specific sevices to them IPA( Independent Physician/Practice Association) - Precise Answer ✔✔Contracts with independent physicians practicing individually or in single specialty groups; these physicians also usually see fee- for-service patients ( non-HMO) as well. They are paid by capitation for the HMO patients and by traditional means for their non-HMO patients POS( Point of Service) - Precise Answer ✔✔Patients can receive care by both physicians contracting or not contracting with the HMO. This sometimes called an "open-ended" HMO. Physicians not contacting with the HMO but who see HMO patients are paid according to the services provided. The patient is incentivized to see contracted providers within the HMO HEDIS - Precise Answer ✔✔An acronym for Health Plan Employer Data and Information Set. HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. It is a set of performance measures that are utilized to assist employers and other health purchasers in understanding the value of health care purchases and evaluating health plan performance. Considered a quality measurement. this is a way for health plans to simplify and standardize measurement and reporting. Currently , HEDIS consists of 71 measures across eight care domains. HEDIS makes it possible to compare the health plan performance on a comparable basis. Health plans also use HEDIS measures themselves to see where they need to focus their improvement efforts. Some examples of HEIDS measures include: Childhood immunizations, use of appropriate medications in people with asthma, controlling high blood pressure, and flu shots for adults 50 years and older. Physicians are required to comply to HEDIS guidelines for recredentialing with most HMO Plans. HHA - Precise Answer ✔✔an acronym for " home health agency" HIV - Precise Answer ✔✔an acronym for "human immunodeficiency virus" Home Health Agency - Precise Answer ✔✔A legally operated facility that primarily provides skilled nursing services to patients in their homes. It operates under the direction of a Doctor of Medicine or Doctor of Osteopahty. It maintains clinical records and qualifies as a home health agency under Medicare. It does not include any facility that primarily provides care or treatment for mental disorders Home Care - Precise Answer ✔✔In contrast to inpatient and ambulatory care, home care is medical care ordinarily administered in a hospital or on an outpatient basis, however, the patient is not sufficiently ambulatory to make frequent office or hospital visits. For these patients, intravenous therapy, for example is administered at the patient's residence, usually by a health care professional. facilities. This non-profit organization audits these facilities and was previously known as the Joint Commission for the Accreditation of hospitals. Legend Drug - Precise Answer ✔✔another name for a prescription drug. It bears the legend, " Caution: Federal Law prohibits dispensing without a prescription" Length of Stay - Precise Answer ✔✔The number of consecutive days a patient is hospitalized. It is abbreviated as LOS Lifestyle Drugs - Precise Answer ✔✔Drugs designed to improve the quality of life or extend the normal life span. They generally are not used to treat a life-threatening disease. These may include drugs that would restore or improve sexual potency, enchance weight loss, restore hair growth, or reverse the effects of aging. These drugs are often excluded from coverage in MCOs and other insurance plans. LOS - Precise Answer ✔✔An acronym for " length of stay" Limits - Precise Answer ✔✔A term that describes the ceiling for benefits payable under a plan Long-Term care facility - Precise Answer ✔✔Services that ordinarily are provided in a skilled nursing , intermediate care, personal care, supervisory care, or elder care facility. Loss Ratio - Precise Answer ✔✔The ratio between the cost to deliver medical care and the amount of money taken in by the plan Mail-Order Pharmacy - Precise Answer ✔✔A growing number of HMOs and Pharmacy Benefit Managment ( PBM) companies affiliated with corporations or federal contracts use a mail-order pharmacy program to provide their members with discount drug rates delivered through the mail to their home. Mail-order pharmacies can purchase drugs in large volumes, and therefore the prices tend to be cheaper, which they pass on to the enrollees. some HMOs and PBMs mandate mail-order prescripitons for all long- term ( maintenance) medications. Mandated Benefits - Precise Answer ✔✔Services mandated by state or federal law such as in child abuse or rape, and are not necessarily covered by insurers. Maximum Allowable Charge MAC) - Precise Answer ✔✔An amount set by the insurer as the highest amount to be charged for a particular medical service or pharmaceutical product. MCO - Precise Answer ✔✔An acronym for "managed care organization". It is a generic term for exclusive provider organization (EPO), HMO, and others Medicaid - Precise Answer ✔✔Federal and state health insurance for qualified low-income people. Medical Home - Precise Answer ✔✔Another name for Patient- Centered Medical Home. Medical Waste - Precise Answer ✔✔Any intervention that has no possible benefit for the patient, or in which the potential risk to the patient is greater than the potential benefit. Occurs if the provider is misinformed; if the patient is misinformed and the provider succumbs to patient demands; or if the provider behaves unethically. Medically Necessary and Appropriate - Precise Answer ✔✔The most cost-effective level or type of treatment, care, service, or supply that is consistent with the illness, injury, or other condition under treatment or care, based on the patient's overall medical history, condition, and prognosis, and current, generally accepted medical practice. Medicare - Precise Answer ✔✔The national program that provides medical care to the elderly, certain people with disabilities, and those who have End Stage Renal Disease (ESRD). This program was established by Title XVIII of the Social Security Act. Medicare Plus Choice ( Medicare Advantage Plans) - Precise Answer ✔✔The program of medical care benefits established by Title XVIII of the Social Security Act, providing an HMO option. Extra benefits and lower co-pays are typical. Non-Network Provider - Precise Answer ✔✔Any provider not meeting the policy definition of a network provider at the time treatment, care, services, or supplies are provided Nonparticipating Provider ( also called a Non-par provider) - Precise Answer ✔✔A health care provider who has not contracted with the carrier or health plan to be a participating provider of health care within that particular plan or insurance. NTOCC - Precise Answer ✔✔An acronym for National Transitions of Care Coalition. Off-Label Use - Precise Answer ✔✔The use of a drug for clinical indications other than those stated in the product labeling approved by the Food and Drug Administration (FDA). For example, if there was a drug that received FDA approval for treating diabetes and it was being used to treat cancer, its use would be off-label in this particular case. This is often done with cancer drugs, where it is approved for certain cancers but not others. OOA( Out-Of Area)Charge - Precise Answer ✔✔A covered charge for treatment, care, services, or supplies provided by a non-network provider to a patient who resides outside the PPO area (whether or not the provider is located outside the PPO area). Covered charges are defined, with limits and exclusions, under major medical expense benefits and medical care benefit exclusions. OON ( Out of Network ) Charge - Precise Answer ✔✔A covered charge for treatment, care, services, or supplies provided by a non- network provider to a patient who resides inside the PPO area (whether or not the provider is located inside the PPO Area). Covered charges are defined, with limits and exclusions, under major medical expense benefits and medical care benefit exclusions. Open enrollment period - Precise Answer ✔✔The period during which an MCO allows people not currently enrolled in their plan to sign-up for plan membership OTC - Precise Answer ✔✔An acronym for over-the-counter, which usually refers to non-prescription drugs. Out -of Plan - Precise Answer ✔✔This refers to choosing a provider who is not a member of the preferred provider network. Out-Of -Pocket Costs - Precise Answer ✔✔The share of health services payment made by the enrollee, or the expenses that the enrollee must pay on his/her own Out-of-Service Area - Precise Answer ✔✔This refers to medical care received out of the geographic area that may or may not be covered, depending on the plan Outpatient - Precise Answer ✔✔A person who receives treatment, care, services, or supplies other than in an inpatient or partial hospitalization setting. Patient-Centered Medical Home - Precise Answer ✔✔An approach to providing comprehensive primary care that facilitates partnerships between individual patients, their personal providers, and when appropriate, the patient's family. May allow better access to health care, increased satisfaction with care, and improved health. Patient Protection and Affordable Care Act - Precise Answer ✔✔Signed into law on March 23, 2010. Commonly referred to as "health care reform" when taken in conjunction with the Health Care and Education Reconciliation Act of 2010. P & T Committee - Precise Answer ✔✔An abbreviation for Pharmacy and Therapeutics Committee. The P&T committee is an advisory committee responsible for developing, managing, updating, and administering the drug formulary system. P&T committees are also usually charged with developing and/or approving drug-related guidelines or programs within the health-system. P&T Committees can be found in MCOs, PBMs, hospitals and other related health systems and are usually comprised of PCPs, specialty physicians, pharmacists, and other health care professionals. Committee members may also include nurses, legal experts, and administrators PA - Precise Answer ✔✔An abbreviation for physician assistant. POS - Precise Answer ✔✔An acronym for Place of Service/Point of Service/Point of Sale. Preadmission Certification - Precise Answer ✔✔The practice of reviewing claims for hospital admission before the patient actually enters the hospital. This cost-control mechanism is intended to eliminate unnecessary hospital expenses by denying medically unnecessary admissions. Pre-Certification ( also Known as Pre-Authorization or Pre-auth) - Precise Answer ✔✔In managed care it refers to the approval of care, such as a hospitalization, certain diagnostic tests, or even non- covered medications. Preauthorization may be required before admission takes place or care is given by non-managed care providers. Pre-Existing Condition - Precise Answer ✔✔Any medical condition that has been diagnosed or treated within a specified period before the member's effective date of coverage under the group contract. There is often a short delay in beginning coverage when a pre- existing condition is present. Preferred Providers - Precise Answer ✔✔Physicians, hospitals, and other health care providers who contract to provide health services to persons covered by a particular health plan. Prescription Drugs - Precise Answer ✔✔Medicines which can only be obtained by law with a qualified practitioner's written prescription. For the purposes of the policy, nitroglycerin, insulin, and insulin injection syringes are also often deemed to be prescription drugs. Preventive care - Precise Answer ✔✔Health care emphasizing priorities for prevention, early detection, and early treatment of conditions, generally including routine physical examination, immunization, and well-person care. Primary Diagnosis - Precise Answer ✔✔The code reflecting the current, most significant reason for the services or procedures provided. If the disease or condition has been successfully treated and no longer exists, it is not billable and should not be coded. Provider - Precise Answer ✔✔Any supplier of health care services; ie, physician, pharmacist, case management firm, etc. QualityAssurance(QA) - Precise Answer ✔✔Quality assurance or quality assessment is the activity that monitors the level of care being provided by physicians, medical institutions, or any health care vendor in order to ensure that health plan enrollees are receiving the best care possible. The level of care is measured against pre-established standards, some of which are mandated by law. Quality Managment( QM) - Precise Answer ✔✔The monitoring and maintenance of established standards of quality using techniques proposed by Crosby, Demming, and Juran Reasonable and Customary - Precise Answer ✔✔Usual, customary, and reasonable services or costs. Reinsurance - Precise Answer ✔✔Insurance purchased by a payer to protect from extremely high losses. Retrospective Review - Precise Answer ✔✔A process of judging medical necessity and appropriate billing practices for services which have already been rendered. Second Opinion - Precise Answer ✔✔Obtaining another professional's opinion to help determine the necessity of a medical procedure or drug treatment. This is often required by plans before a surgical procedure. Self-Insured or Self Funded plan - Precise Answer ✔✔A plan where the risk is assumed by the employer rather than the insurer. Service Date - Precise Answer ✔✔The date a charge is incurred for a service TPL - Precise Answer ✔✔An acronym for "third-party payers"; they are liable for the cost of an illness or injury, such as auto or homeowner insurer. Transition of Care - Precise Answer ✔✔A series of actions that ensures continuity of health care delivery as patients navigate through the system. Refers to a patient moving from one level of care to another, such as from primary care to specialty physicians; from the emergency department to surgery or intensive care; or when patients are discharged from the hospital to home, to an assisted living arrangement, or to a skilled nursing facility. UB-92 - Precise Answer ✔✔An abbreviation for Uniform Billing Code of 1992. It is the common claim form used by facilities to bill for services. UCR - Precise Answer ✔✔An acronym for "usual, customary, and reasonable Underwriting - Precise Answer ✔✔Evaluating and determining the financial risk a member or member group will have on an insurer. UPIN - Precise Answer ✔✔An acronym for "unique physician identification number". UR - Precise Answer ✔✔An abbreviation for Utilization Review. UR is performed by the HMO to discover if a particular physician- provider or other provider (eg, pharmacy) is spending as much of the HMO's money on treatment or any specific portion thereof (eg, specialty referral, drug prescribing, hospitalization, radiologic or laboratory services) as his or her peers. URAC - Precise Answer ✔✔An acronym for Utilization Review Accreditation Commission. One of the accrediting bodies of health plans. Urgent Care Center - Precise Answer ✔✔A medical facility in which ambulatory patients can be treated on a walk-in basis, without an appointment, and receive immediate, non-emergency care. The urgent care center may be open 24 hours a day. Patients calling an HMO after hours with urgent, but not emergent clinical problems, are often referred to these facilities. Usual, Customary and Reasonable (UCR) - Precise Answer ✔✔Usual, Customary, and Reasonable (UCR) Fee-for-service payment to physicians based on the usual and customary fee for the same service in the area where the practice is located or on some other judgment of reasonable payment Worker's Compensation - Precise Answer ✔✔Laws requiring employers to furnish care to employees injured on the job. Services performed under worker's compensation policies are usually excluded from commercial health plan coverage. Algorithms - Precise Answer ✔✔Also known as a Decision Tree: These are designed to reflect current standards of practice and aid in the decision-making process. Unlike pathways or guidelines, algorithms are considered to be precise interventions, often termed "cookbook medicine" Care maps - Precise Answer ✔✔these are also called care pathways. They embrace continuing care, instead of a timed episode of care. these are primrily used in the post-acute setting and have more detail than a clinical patheway in areas that cover function, therapies, discharge planning and psychosocial needs. They are not as specific and directed as clinical pathways, and the patients for which the care map is used do not fall eaily into treatment categories Clinical Pathway - Precise Answer ✔✔Time, activity and event are featured in a grid format that outlines categoreis of interventions on one axis( usally the vertical) and time ( or other indicators of clincial progression on the other axis. Time can be measured in minutes to years or in activities or specific task performed to arrrive at an expected outcome. the events shown on a pathway are observable milestones that reflect progress toward the expected outcomes. Patient Care Guidelines - Precise Answer ✔✔Practice guidelines that include times, tested methods of describing practice patterns. The guidelines are useful informing a basis for development of algorithms and clinical pathways. They can become a statement of unity between providers and disciplines in supporting a collaborative practice base.