Healthcare Terminology and Concepts, Exams of Advanced Education

Download Healthcare Terminology and Concepts and more Exams Advanced Education in PDF only on Docsity! CCM Exam With 100% Correct Answers 2023 HMO - Correct Answer-health maintenance organization ACO - Correct Answer-Accountable Care Organization Viatical Settlements - Correct Answer-ability to sell own insurance policy CHAMPVA - Correct Answer-Civilian Health and Medical Program of the Veterans Administrationtr CHAMPVA for Life - Correct Answer-provides healthcare benefits to families of permanently disabled veterans, or killed in line of duty, not eligible for tricare. Covers 65 or older, is a Medicare supplement. TRICARE - Correct Answer-is a U.S. government health insurance plan for active military personnel, national guard, reserves, retirees, their families and some former spouse's. TRICARE for Life - Correct Answer-primarily a supplemental insurance with those with Medicare A & B coverage, &eligible for TRICARE in US. Is the primary insurance overseas. advance directives - Correct Answer-A signed document indicating that the person's wishes regarding care during dying. ASO - Correct Answer-administrative services only, and insurance company or TPA that provides administrative services for an employer group. Adverse Events - Correct Answer-any untoward occurrences not of natural consequences. Advocacy - Correct Answer-support; active pleading on behalf of someone or something Alternate level of care - Correct Answer-level of care used safely in place of current level, determined by acuity. Assessments - Correct Answer-The process of collecting in-depth information about a persons situation and function to identity needs. assistive device - Correct Answer-tool, software, or hardware to assist in performing daily activities Assistive technology - Correct Answer-equipment or products used by individuals with disabilities to improve functioning in activities Autonomy - Correct Answer-person's right to self determination and independence Beneficence - Correct Answer-Doing good or causing good to be done; kindly action Beneficiary - Correct Answer-a person who derives advantage from something, especially a trust, will, or life insurance policy. Benefit package - Correct Answer-the sum of services a health plan, government agency, or employer contracts to provide. Benefits - Correct Answer-the amount payable by the insurance company to a claimant or beneficiary under claimant s coverage. Brain injury - Correct Answer-Any brain damage that impairs normal functioning of the brain, either temporarily or permanently Burden of proof - Correct Answer-the obligation facing a persuasive speaker to prove that a change from current policy is necessary Capitation - Correct Answer-fixed amount of money per member-per-month paid to care provider for covered services. CARF - Correct Answer-commission on accreditation of rehabilitation facilities, private, non profit organization that establishs standards of quality services for people with disabilities. Carve outs - Correct Answer-services that are excluded from a provider contract, provider not responsible for services carved out of contract Caseload - Correct Answer-total number of patients followed by a case manager at any point in time. case management - Correct Answer-collaborative process that assesses, plans, implements, coordinates, monitors &evaluates options and services to meet needs of individuals. Case Management System - Correct Answer-a computer program that helps a counselor organize information used to serve a specific client Case mix index (CMI) - Correct Answer-sum of DRG-relative weights of all patients seen in years time divided by patients hospitalized Independent Practice Association (IPA) model - Correct Answer-a legal entity(private practice) sponsored by physicians that contracts with HMO : bound by terms of contract Network model - Correct Answer-An organizational arrangement in which an HMO contracts with more than one medical group practice. A provider network Staff Model HMO - Correct Answer-group of physicians who work and are paid by the HMO and see only HMO patients Handicap - Correct Answer-condition that interferes with a person's ability to function normally Health Insurance - Correct Answer-Provides money to pay for health care for illness, injury, or in some cases preventive care. Healthcare Maintenance Organization HMO - Correct Answer-an organization that provides or arranges for coverage of health services for fixed fee Hospice - Correct Answer-A type of care for terminally ill patients; an organization that provides such care ICD 10 - Correct Answer-International Classification of Diseases, Tenth Edition, used for coding MR for reimbursement Indemnity Benefits - Correct Answer-the provider bills the patient for services, insurance reimburses patient Informed Consent - Correct Answer-consent given by patient, next of kin, legal guardian for services Inpatient Rehabilitation - Correct Answer-eligibility: tolerate 3 hours of therapy/day, require skilled service Managed care - Correct Answer-is an approach that has developed in response to rising health care costs Levels of Care - Correct Answer-the intensity of effort required to diagnose, treat, preserve or maintain an individuals functional status Length of stay - Correct Answer-The number of days a person stays in a healthcare facility. JCAHO stands for: - Correct Answer-joint commission on accreditation of health care organizations Integrated delivery system - Correct Answer-single group of organizations that provide care across a continuum of settings Maximum Medical Improvement MMI - Correct Answer-injured worker is at level physician determines further treatment will not change outcome long term disability - Correct Answer-insurance issue to an employee group or individual to replace a portion of an individual's income lost as a result of serious prolong illness during the normal work career Malpractice Insurance - Correct Answer-insurance to cover liability assumed during practice malpractice - Correct Answer-Improper care or treatment by health care professional. Wrong conduct, negligent. Medicaid - Correct Answer-a joint federal and state program that provides basic health insurance for persons with disabilities for or who received certain government benefits(ssi) Medicare Part A - Correct Answer-basically covers inpatient hospital expenses for patients who meet certain conditions Medicare Part B - Correct Answer-Outpatient care. Extends Medicare to supplemental treatments, and physicians Minimum Data Set (MDS) - Correct Answer-assessment to used in SNF to place patients in RUG to determine reimbursement Medical durable power of attorney - Correct Answer-a legal document that names a surrogate decision-maker in the event the patient is unable to make decisions Network model HMO - Correct Answer-HMO contract directly with IPA, medical groups & independent Physicians forming a provider Network, organized referrals Nonmaleficence - Correct Answer-do no harm Per diem - Correct Answer-daily allowance Point of Service (POS) - Correct Answer-a combination of a PPO and HMO plan using a contracted network of providers and PCP as Gate Keeper to control referrals. out-of- network services incur higher deductible Pre-admission Certification - Correct Answer-utilization review process that examines proposed Services before admission Pre-Authorization/Pre-Certification - Correct Answer-process of obtaining & documenting approval for health plan befor delivery of Medical Services Preferred Provider Organization - Correct Answer-PPO, preferred provider group/ organization where group of medical providers provide medical services on a negotiated fee Primary care physician (PCP) - Correct Answer-provider who assumes ongoing responsibility for overall health treatment of a patient Prospective review - Correct Answer-Reviewing possible hospitalization before admission to determine necessity and LOS HEDIS HealthCare Effectiveness Data Information Set - Correct Answer-performance measurement set for MCO to set quality of systems Quality Assurance - Correct Answer-Use of activities and programs ensuring quality of patient care Quality Improvement - Correct Answer-process used to identify and resolve deficiencies and improve care outcomes Reasonable Accommodation - Correct Answer-make an existing facility accessible and usable for individuals with disabilities; can include job adaptation for individuals Resource utilization groups (RUGs) - Correct Answer-classifiies SNF patients into 7 major hierarchies and 44 groups, based on MDS for reimbursement Root Cause Analysis (RCA) - Correct Answer-process to identify underlying factors that contribute to variation in outcomes in sentinel event Risk Sharing - Correct Answer-HMO &PROVIDER share financial risk/rewards of caring for plan members Self-insured - Correct Answer-an employer that meets the state legal and financial requirements to assume all of its health care costs for its employees Staff Model HMO - Correct Answer-Physicians are on the staff of the HMO and provide care exclusively for the health plan enrollees Third Party Administrator (TPA) - Correct Answer-an organization separate from the insurer that handles administrative functions such as review claims & UR Veracity - Correct Answer-truthfulness Social Security disability insurance(SSDI) - Correct Answer-a federal program that provides supplemental income to people who have employment restrictions due to disability Failure to thrive - Correct Answer-weight for age that falls below percentile health literacy - Correct Answer-the ability to obtain, communicate, process, understand and make health care decisions Test of Functional Health literacy assessment (TOFHLA) - Correct Answer-complex assessment consists of two parts (numbers/documents & reading comprehension) to assess health literacy Rapid Estimate of Adult Literacy in Medicine (REALM) - Correct Answer-assesses the ability of adult pt to read medical words& lay terms for illnesses & body parts Polypharmacy in Older Adults - Correct Answer-Inadvertent prescriptions from multiple medications from multiple providers Reverse mortgage - Correct Answer-an option for a patient who is a homeowner and 62 years of older to borrow against for health care needs Accelerated Death Benefits - Correct Answer-an insurance policy Rider allow an insurer personal with a terminal illness to use policy benefits prior to dying Dementia - Correct Answer-An abnormal condition marked by multiple cognitive defects that include memory impairment. Actuarial study - Correct Answer-is a statistical analysis of a population based on its utilization of specific is healthcare services and demographic trends Appeals - Correct Answer-formal process or request to reconsider Healthcare decision(denials) Extra-contractual benefits - Correct Answer-benefits not covered under the health plan but are given to the insured for cost savings Pharmacy Benefit Management (PBM) - Correct Answer-services used to control the cost of prescription drugs COBRA - Correct Answer-Consolidated Omnibus Budget Reconciliation Act insurance coverage after job loss COBRA - Correct Answer-ability to retain Insurance due to a catastrophic change ex: job loss, decreasing work, divorce, lasts up to 36 months at a higher rates Mental Status Exam - Correct Answer-broad preliminary assessment of behavior and mental state PHQ-9 - Correct Answer-assessment that evaluates degree of depression DSM-IV - Correct Answer-A guide used for the diagnosis of psychiatric and mental health disorders Cost-benefit analysis - Correct Answer-economic model that compares the monetary savings and benefits of a decision Hard Savings - Correct Answer-directly related to case manager's actions, ex: decrease length of stay, price negotiations Soft savings - Correct Answer-cost savings that can't be measured, ex: avoidance of hospital readmission case management plan - Correct Answer-plan developed by IDT Healthcare team in relations to Patient diagnosis problems and surgical procedures First level reviews - Correct Answer-conducted while the patient is in the hospital, care is review for appropriateness Outcome and Assessment information set OASIS - Correct Answer-a nursing assessment instrument completed by Home Health agencies at the time the patient has entered for Home Health Services score determines Home Health Resource Group (HHRG) Quality Indicator - Correct Answer-Measures of outcomes Functional Independence Measures Instrument (FIM) - Correct Answer-used in the Inpatient Rehab setting measures the individual level of Independence/ dependence in ADLs Managed Care - Correct Answer-is a Cost Containment Healthcare System overseen by an organization other than the physician or patient Bundled reimbursement - Correct Answer-care is reimbursed according to expected cost for a clinical episode of care SSDI eligibility requires - Correct Answer-individual must be unable to perform the work they previously did and the disability must be expected to last at least one year or result in death Rancho Los Amigos - Correct Answer-assessment to used to assess cognitive functioning after a traumatic brain injury Axis I - Correct Answer-Clinical disorders (depression, anxiety) Axis II - Correct Answer-personality disorders and developmental disorders Axis III - Correct Answer-General medical conditions Axis IV - Correct Answer-Psychosocial and environmental problems Axis V - Correct Answer-Global Assessment of Functioning that allows the clinician to rate the level of danger to one's self and functioning Glasgow Coma Scale (GCS) - Correct Answer-measures level of coma in the acute phase of an injury Health risk assessment (HRA) - Correct Answer-a tool to assess a patient's health status, risk of negative health outcomes, and readiness to change behaviors HRA components - Correct Answer-questionnaire, risk calculation, and feedback Due diligence - Correct Answer-reasonable steps taken by a person in order to avoid negligent action. Pallative care - Correct Answer-care for seriously ill persons focused on providing relief from symptoms Disorientation - Correct Answer-lack of awareness of self, place, and/or time seen in multitude of conditions Benchmarking - Correct Answer-Method of measuring quality by comparing performance against industry leaders Case rate - Correct Answer-rate of reimbursement that packages pricing for certain category of services Sub-acute Care - Correct Answer-level of care where patient doesn't require hospital care but more intensive than SNF services Skilled Nursing Facility (SNF) - Correct Answer-offers 24-hour skilled nursing and personal care also Rehab Services Intermediate Care - Correct Answer-level of care for patients who require more assistance and custodial care may require nursing supervision but do not need true skilled care Active listening - Correct Answer-essential to negotiating , includes listening to direct and indirect communications Uilization Review Accreditation Commission (URAC) - Correct Answer-non-profit organization that provides accreditation to Health Care organizations Goal of the URAC - Correct Answer-to encourage continued Improvement in quality and efficient Healthcare Management to education and accreditation National Quality Forum (NQF) - Correct Answer-organization that's set standards used to measure public report Healthcare quality Assistive Technology - Correct Answer-array of devices that permit people with disabilities to improve their functioning Non-maleficence - Correct Answer-deals with the practitioner (do no harm) OSHA - Correct Answer-in the Department of Labor to maintain a safe and healthy work environment Family and Medical Leave Act of 1993 (FMLA) - Correct Answer-Requires employers to provide up to 12 weeks of unpaid leave for family and medical emergencies Mental Health Parity Act of 1996 - Correct Answer-prohibits lifetime or annual dollar limits on Mental Health Care unless same limits apply to medical/surgical tx Newborns and Mothers Health Protection Act of 1996 (NMHPA) - Correct Answer-an amendment to title VII of Civil Rights Act of 1964, that cover private/public hospitals length of stay following childbirth, pregnancy must be treated same as other employee related iilnesses Women's Health and Cancer Rights Act of 1998 (WHCRA) - Correct Answer-requires insurance coverage of breast reconstruction following mastectomy HIPAA stands for - Correct Answer-Health Insurance Portability and Accountability Act of 1996 HIPAA - Correct Answer-Title I guarantees health insurance access portability and renewal, prohibits discrimination based on health status Email communication - Correct Answer-non-verbal communication Wickline vs. State of California - Correct Answer-found the CM's are liable for damage if their referral is careless and leads to patient harm Methadone - Correct Answer-used for the treatment of heroin addiction Predictive Modeling - Correct Answer-a data-mining technique used to predict future behavior and anticipate the consequences of change Medicare eligibility - Correct Answer-65 or older, disabled(5month waiting period), Railroad retirement (24 +5months), ESRD Medicare admission criteria for Inpatient Rehab - Correct Answer-admitting Dx, recent loss of ADL, MD DX with potential Improvement, if previously in rehab has to have occurrence that shows pt can reestablish function Prosthesis - Correct Answer-An artificial device to replace/augment a missing/impaired part or all of missing body part Orthosis - Correct Answer-a device used to support a weak or ineffective joint or muscle to restore function DME criteria - Correct Answer-used for medical reason, usually not useful for the sick/injured, long-lasting, using in home DME - Correct Answer-cane, brace, commode chair, crutches, hospital bed, wheelchair Continuum of Care - Correct Answer-5stages: wellbeing, risk factors, clinical s/s of ds, tx for DX, outcome/recovery Palliative care program - Correct Answer-constant review of pt needs and tx, while noting their religious beliefs, cultures & values Risk Management Process - Correct Answer-1. Risk Identification 2. Risk Assessment 3. Risk Response Development 4. Risk Response Control Change agent illness - Correct Answer-any illness that affects an individual's life and physical social or psychological ways Stages of Change - Correct Answer-precontemplation, contemplation, preparation, action, maintenance, termination Cultural Competence - Correct Answer-process of providing care that's respectful and knowledgeable of cultural backgrounds CM Accreditation phase 1 - Correct Answer-1)application Disease Management - Correct Answer-focuses on groups of patients with conditions that have high financial costs and will benefit from integrated systematic management Case Management - Correct Answer-the management of an individual patient, managing care and access to resources CCM certification - Correct Answer-Supervised 12 mons experience as FT CM, 24 mons unsupervised, 12mons supervising CM core components of case management - Correct Answer-processes and relationships, Healthcare Management, Community Resources and support, service delivery, psychological intervention, & rehabilitation case management Justice - Correct Answer-being fair or just, balance of what is best for one patient vs. what is best for larger society Supremacy of values - Correct Answer-feeling that one's own values reign supreme over all those involved Goal of Medication Reconciliation - Correct Answer-decrease med errors, omissions, duplication of drugs, drug interactions, & dosing errors When medication reconciliation should be done? - Correct Answer-patient is moved within a hospital, transfer to another facility, discharge, & at each MD visit Main role of Case manager - Correct Answer-Patient advocate Domains of Case Management - Correct Answer-care delivery/reimbursement, psychosocial concepts, quality & outcomes, rehab, legal Healthcare reimbursement - Correct Answer-one major category of knowledge necessary for case manager Four key Functions of Case Manager - Correct Answer-planner , assessor, facilitator , & advocate Within the walls (WTW) - Correct Answer-refers to activities within the hospital Beyond the Walls (BTW) - Correct Answer-refers to case management in outpatient and Community settings Ostensible Agency - Correct Answer-the relationship that exists between the case manager(agent) and a referral provider Gag clause - Correct Answer-prevents Providers from discussing uncovered(plan) treatment options with the patient indemnity plan - Correct Answer-No INN/ONN, NO PCP, mbr pays deductible, no referrals needed Indemnity payments - Correct Answer-Monies paid as wage replacement for injured worker medically unfit to work . Reserves - Correct Answer-sum of money insurance company or self-insured funds set aside to pay claims cost mental retardation - Correct Answer-subaverage intellectual functioning during developmental period Predictive model - Correct Answer-process used by Managed care organizations to identify target high costs/expenditures and services Outcome and Assessment Information Set (OASIS) - Correct Answer-contains data items developed for measuring patient outcomes for the purpose of performance Improvement in home healthcare, required for all Medicaid and Medicare beneficiaries Pooling risk - Correct Answer-the grouping of high risk beneficiaries critical pathways - Correct Answer-Are healthcare provider documents that detail the main elements of day to day care activities necessary for a typical patient with a specific diagnosis chronic care model - Correct Answer-created to address deficiencies in chronic care, the Aging population and patients with chronic conditions. Can be applied to many chronic conditions in many healthcare settings Case finding in case management essential activities - Correct Answer-involves 1. dentification through referrals, 2. is diagnosis driven, 2. high-dollar referrals, 3) and repeated service requests Key component of Case Managers job - Correct Answer-follow-up and monitoring Injured Workers - Correct Answer-can change provider one time without prior approval from insurance company Contemplation stage - Correct Answer-getting ready to change possibly within 6 months Precontemplation - Correct Answer-Not intending to change behavior. Change theory (Kurt Lewin) - Correct Answer-1 precontemplation, 2 contemplation, 3 preparation, 4 Action , 5 maintenance Milliman care guidelines - Correct Answer-considered general recovery guidelines Hospital length of stay - Correct Answer-calculated in days, for newborn begins at the time of the delivery or last time of delivery in the event of multiple births. if the delivery occurs outside ohospital begins at time mother or newborn is admitted in hospital Transitional Care - Correct Answer-the actions to assure coordination and continuity of care as patient transfer between different locations or different locations within same facility transitions of care - Correct Answer-refers to the movement of patients between locations Healthcare Providers or different levels of care within same facility. Narrow subset of the broader concept of Transitional Care Persons vulnerable for pitfalls in transitions of care - Correct Answer-non English- speaking, different cultural backgrounds, children with special needs, frail elderly person, cognitive impairments, complex conditions, disabilities, low-income continuum of care - Correct Answer-1. well-being/independence, 2. risks factors/behaviors, 3. medical problem, 4)treatment ,5)outcome Lions club - Correct Answer-vision resource, and disabilitie, diabetic prevention and treatment Rotary International - Correct Answer-first focuses on six areas for grants:, two focus on Health disease and prevention( HIV/AIDs) maternal and child health. Knights of Columbus - Correct Answer-provides funding for charitable endeavours with a focus on disabilities Hospice - Correct Answer-MedicareA covers two 90day & unlimited 60day benefit periods, with physician revert every 60days Covered by Medicare Part B - Correct Answer-DME, 80% covered if prescribing physician and supplier are Medicare enrollees