HIT ALT/COMP REVIEW FINAL

Explain the following types of care given to end-stage renal disease patients: hemodialysis, CAPD, and CCPD.

"Hemodialysis (HD)- "the patient's blood circulate outside the body through an artificial kidney that removes metabolic wastes and helps maintain homeostasis. When patient is expected to be a long term hemodialysis, surgery is generally required. To keep the body free of excessive waste products, the patient generally dialyzes 3 times per week for 3-5 hours per session. Can receive treatment in freestanding dialysis facilities, dialyzes unit of hospital, or in own homes". • Continuous ambulatory peritoneal dialysis (CAPD)- "the patient is able to perform his or her own dialysis almost anywhere, because very little special equipment is needed. The CAPD patient dialyzes 3-4times a day, at home or work". • Continuous cycling peritoneal dialysis (CCPD)- "untilizes a machine to perform peritoneal dialysis once each day while the patient sleeps rather then 3- 4 time throughout the day. Like CAPD patients, CCPD patients generally come to the ESRD facility only for training and for monthly evaluations or when a complication arises."

Services provided by a NP or PA while a physician is on site and services are termed ________ and are fully reimbursed.

"incident to"

Data in Uniform AC data set? How this set affects content of Ambulatory Record?

-Patient Data, Provider Data & Encounter Data -Provides guidance on what should be kept in patient record. Provides standard definitions for items collected.

An HMO with 50,000 members had 13, 024 inpatient service days for last month. What formula would you use to determine bed days per 1,000, and what was this HMO's rate for last month?

...

What types of QAPI activities take place in dialysis facilities?

1. Adequacy of dialysis 2. Nutritional status 3. Mineral metabolism and renal bone disease 4. Anemia management 5. Vascular access 6. Medial injuries and medical errors identification 7. Hemodialyzer reuse program, if the facility reuses hemodialyzers 8. Patient satisfaction and grievances 9. Infection control

What 3 characteristics are required for an organization to qualify as an HMO?

1. An organized system for providing health care or otherwise assuring health care delivery in a geographic area. 2. An agreed-upon set of basic and supplemental health maintenance and treatment services. 3. A voluntarily enrolled group of people.

What 2 benefits will the MCO realize from using online referral processing?

1. It allows the MCO to direct patients to appropriate providers in the network. 2. It allows the MCO to estimate future expenses associated with the referred care

How did the "duty to warn" originate, and how does it affect confidentiality of mental health information?

1976 court decision that states that a therapist has an obligation to warn persons against whom their clients make threatening statements. Duty to warn is exempted from pt/doctor privilege

Which of the following groups does NOT publish standards for some type of ambulatory health care? A) The Joint Commission B) Accreditation Association for Ambulatory Health Care C) Commission for the Accreditation of Birth Centers D) American Association for On-Site Health Care

American Association for On-Site Health Care

Why wouldn't a managed indemnity plan collect referral data?

Because patients are allowed to see other providers if they are willing to pay the additional cost.

What are the benefits of an EHR to a physician practice and its patients?

Being able to collect pt health info and having it available throughout the network of facilities. Physicians get an additional $20,000 to those who utilize an electronic prescribing system and the PQRI. Their medicare reimbursement would decrease w/o adopting the EHR.

What resources would a health information consultant find helpful in consulting for ESRD facilities?

Being able to consult them, the consultant must first visit the unit and review sample records

Superbill

Billing form including services rendered, charges, diagnoses, and procedure codes.

An appointment scheduling method that assigns all patients in a large block for the same appointment time (e.g., 9:00 a.m. for all morning appointments), then patients are seen on a first-come, first-served basis is called a ______________.

Block Appointment system

Which of the following is NOT a characteristic of Urgent Care Centers? A)Generally no appointment system B)Extended hours/days of operation C)Often "not-for-profit," charging reduced fees D)Provide routine care or treat minor emergencies

C) Often "not-for-profit," charging reduced fees

What certifications can health professionals working in corrections receive, and through which organizations are the programs administered?

Certified Correctional Health Professional Program (CCHP) administered by the National Commission on Correctional Health Care. Correctional Cer6tification Program (CCP) offered by the American Correctional Association to correctional officers, correctional staff, staff nurses, and nurse managers working in corrections

Explain the difference between coinsurance and copayment.

Coinsurance is the amount of expense that is the responsibility of the insured under and indemnity insurance policy, usually 20 percent. Copayment is a flat-rate payment, such as $10 per visit, made by the covered individual for a specific service at the time of service.

Compare/Contrast fee-for-service and PFS/RBRVS.

FFS patients pay according to the type and amount of service provided. There are separate fees for labs, tests, etc. Although RBRVS is still a fee-for-service system of payment, the reimbursement is based on CMS's estimation of the value of physician's service

Identify the types of consumer-directed health plans and their characteristics.

Flexible spending account- tax-free money an employee sets aside to use during a specified period for health care expenses. Health Reimbursement Arrangement- a mechanism by which an employer funds an account for its employees to pay for otherwise unreimbursed health care expenses. Health Savings Account- an account set up by an employee w/ pretax income that is also not taxed when the employee withdraws from the account for medical expenses. Amounts left in the account at the end of the benefit year roll over to the next year. Withdrawals for non-medical expenses are subject to income tax and a 10 percent penalty

Why could the discounted charges reimbursement mechanism seem attractive to both the physician and the MCO?

For the MCO, this method is the easiest to accomplish, offers the greatest financial risk, and gives little financial incentive to the provider to practice more cost-effectively. For the provider, they recieve payment from the MCO by means of one or more reimbursement mechanisms.

A core set of standard performance measures for managed care in the areas of quality, access and patient satisfaction, membership, utilization, finance, and health plan management is named ______________.

HEDIS

What coding systems would be used to code a hospital claim submitted to an MCO for payment? What systems would be used for a physician claim?

ICD- hospital claim HCPCS- physician claim

How does documentation in an industrial health center differ from that in a physician's practice and why?

In industrial health there are special documentation requirements including new-hire physical, return-to-work physical, transfer/promotion and annual physical, health monitoring, and auditory and vision records.

Why is it crucial for an MCO to conduct utilization management activities?

It is part of the quality improvement function as well as a method of cost control.

What is the significance of Estelle vs. Gamble to correctional health care?

It supplants the idea that all prisoners all human beings and must receive the same amount of health care and respect as any other individuals. The failure to provide the appropriate medical care would still be considered malpractice within the prisons of the incarcerated individuals. Thus, documentation must be concise so a scenario where the inmate Gamble does not occur where an inmate did not receive the right treatment for his medical conditions.

What is the source of payment for most pts who have been on dialysis for more than 30 months?

Medicare Part A is the source of patients who have been on dialysis for over 30 months. Medicare part A is the secondary payer for the first thirty months of treatment, and then becomes the primary payer for patients on chronic dialysis.

The method for physician reimbursement currently in place based on relative value units is the

Medicare Physician Fee Schedule

A managed care organization (MCO) that undergoes evaluation of its ability to perform as an insurance provider will request accreditation from _______________.

NCQA

Patient Identifiers used in AC

Patient Name Unit/Serial number SSN Family Numbering

Major types of documentation that are basic to all ambulatory care encounters and settings

Patient Registration/Demo Info History and Physical Lab/X-Ray Reports Progress Notes Encounter Form Copies of Hospital Records Problem List

What does the abbreviation PMPM mean, and why is it important in managed care?

Per Member Per Month PMPM is used to describe the amount of money paid for the monthly capitation rate per patient, a frequently used reimbursement method in managed care

Types of Freestanding Ambulatory Care

Physician Private Practice Public Health Department Community Health Center Rural Health Clinics Urgent Care Ambulatory Surgery Centers Industrial/ Occupational Health University Health Centers Birth Centers/Family Planning Centers

List the different types of correctional facilities.

Prison-individual facility, unit of state/fed. government. Jail-operated by local units (cities, states) Juvenile Detention Facilities Bureau of Immigration and Customs Enforcement Correctional facilities operated by Army, Navy, Air Force, or Marines.

Why would an MCO want to reimburse hospitals by a DRG payment?

Promotes deliverance of cost-effective patient care without sacrificing quality of care.

Nurse Practitioner

RN with limited independent practice

What are the possible roles for the health information manager in organizations dealing end-renal disease?

The HIM professional is concerned with procedures related to the documentation, storage, retrieval and security of individual patient records. Also may provide advice on the development of systems to provide timely, appropriately accessible patient information to caregivers and administrators.

What are the advantages of placing the health services program within the state department of corrections under a health services director as opposed to placement under individual wardens?

The HSD has both clinical and administrative experience

Two main organizations that accredit AC

The Joint Commission Accreditation Association for Ambulatory Health care, Inc.

What contributed to the introduction of consumer-directed health plans?

The employer need to curtail the double-digit premium increases they were experiencing every year. The frustration felt by physicians and consumers over the restrictions and complexity of managed care.

Briefly describe the accreditation process. Explain options for the accreditation of correctional healthcare programs.

The facility should complete a self-assessment and then complete an application w/ basic info about the facility. Then an on-site survey will take place and members of the survey team review their findings and submit a report to an accreditation committee. Correctional facilities can be accredited by the NCCHC, ACA, and the APHA. All except the APHA are voluntary.

How is quality assessment in ambulatory care similar to and different form quality assessment in the acute inpatient setting?

The similarities are that problems and processes must be chosen for study, data must be collected to measure these processes, data must be assessed, and a method for improvement must be developed. The major difference in ambulatory care is that many factors affecting the quality of care are not within the sole control of ambulatory facility. PT contact is brief and outcomes depends largely on PT's compliance w/ care plan.

Compare and contrast ESRD Networks with quality improvement organizations.

They perform their work under contract w/ CMS. In addition, ESRDs also collect and analyze data on ESRD pts in their regions. The networks monitor pt status changes and deal w/ pt grievances. The also publish an annual report of these and other activities.

How are correctional institutions affected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)? In what ways do HIPAA rules apply differently to the correctional setting?

When a correctional facility is considered a covered entity, it may designate itself as a "hybrid covered entity, which is an organization whose activities include both covered and noncovered functions". It would also need to "appoint a privacy officer, to promulgate policies and procedures protecting the privacy of inmate health information, and to allow inmate access to their health records as a general rule". Correctional institutions are granted an exception to the access rule when such access would "jeopardize the health, safety, security, custody, or rehabilitation of the individual or of other inmates, or the safety of any officer, employee, or other person at the correctional institution or responsible for transporting of the inmate. The privacy rights of inmates is returned to a normal citizen upon release from custody and all their private medical information is covered under HIPAA

Explain the difference between serious emotional disturbance and serious mental illness.

age disturbance = less than 18 illness= 18 and over

Name the main components of the mental health consumer case record.

assessment, treatment plan, progress notes,special procedures(physical/chemical restraints), discharge summary and aftercare plans

Name the three most prevalent types of serious mental illness.

clinical depression, bipolar disorder,schizophrenia

Give a term by which persons with mental illness who are living in the community prefer to be called.

consumer, user of mental health services or survivor

Define "outpatient commitment."

courts placing people in need of psychiatric care in outpt programs with stipulations regarding taking medications and scheduled psychiatric visits

How does an MCO perform coordination of benefits?

determining who the primary insurance payer is and ensuring that no more than 100 percent of the charges are paid to the provider and/or reimbursed to the patient.

Ensuring that a provider is not under utilizing services and compromising the health of managed care members or over utilizing services and creating unnecessary expense is ________________.

economic credentialing

Provide examples of the national outcome measures (NOMs) for which client-level data are reported.

employment-school attendance, stability inhousing, crimnal justice involvement, readmission to state hospita, access capacity

encounter

face-to-face contact between patient and provider

Who performs regular surveys of dialysis facilities? Who performs validation surveys of dialysis facilities?

federal surveyors may conduct an unexpected validation survey to determine whether the state agencies to whom the regular surveys have been delegated are appropriately evaluating facilities according to federal regulations. Even though the primary purpose of the validation survey is to serve as a check on the state surveying agency, any deficiencies noted in the validation survey must still be corrected by the dialysis facility.

What is the basis for payment in the inpatient psychiatric facility prospective payment system (IPF PPS)?

federally determined per-diem rate

What are two categories of dual diagnoses?

mentally ill with intellectual/developmental disability (mental retardation) and mentally ill with alcohol or chemical addiction

What items of info should be documented for each dialysis pt?

patient assessment and patient plan of care

One aspect of Medicare managed care is that _____________.

premiums to HMOs are risk-adjusted based on patient diagnoses

What is the relationship between the treatment plan and progress notes, and why is it important?

progress notes mark the achievement or lack there of in the attempts of the consumer to reach the goals of the treatment plan. Accreditation surveyors often chick to see that every goal in a treatment plan has corresponding progress notes

Reason for Visit

reason why care is being provided

What role do the ESRD networks play in the collection and aggregation of data on dialysis pts?

they "process and analyze data provided by the ESRD facilities and provide other types of services, such as patient education"

What are the URS tables?

uniform reporting system-system by which the state mental health authority (SMHA) reports aggregate data(for mental health statistics) to SAMHSA (substance abuse and mental health services administration)