Case managers use biometric screening and health risk assessment tools to classify clients into low, moderate, or high risk categories. This allows for proper interventions based on the client's needs
What is Stratifying Risk?
100
A study that is a statistical analysis of population based on its utilization of healthcare services and demographic trends of the population
What is Actuarial Study
100
These is a private benefit that is in the form of payments rather than services. They also are known as fee-for-service.
What is Indemnity
100
These are two main reimbursement categories for paying for healthcare are.
What is fee-for-service and episode-of-care
100
The transformation of healthcare diagnoses, procedures, and medical services into universal alphanumeric codes.
What is Medical Coding
200
Willingness to make concessions so that it is win-win for all
What is Negotiation?
200
What are the 5 Federal Workers' Compensation Programs
What is the Federal Employment Compensation Act, Federal Employment Liability Act, Merchant Marine Act, Longshore and Harbor Worker's Compensation Act, and Black Lung Benefits Act.
200
This is a public benefit that is only covered if followed with in 30 days of a hospital stay of 3 or more days and is medically necessary. There are only 100 days to this benefit and copayment required for days 21 to 100.
What is a skilled nursing facility coverage under Medicare
200
This is a method of reimbursement in which payment is made based on a predetermined, fixed amount. Providers know how much they will be reimbursed by the insurance company in advance and can either make money or lose money on the reimbursement
What is the Prospective Payment System
200
This coding system assigns a number or alphanumeric to describe diseases, traumas, and environmental circumstances leading to bodily harm.
What is International Classification of Diseases
300
The purpose to decrease adverse drug events by reducing medication errors such as omission, duplication, drug interaction, and dosing errors
What is Medication Reconciliation
300
The laws that protect employees who are injured or disabled on the job. The employer is 100% responsible for paying for this type of insurance
What is the Workers' Compensation Insurance
300
This is a public coverage that can only be obtained if the member is terminally ill with a life expectancy of six months or less. There is no deductible.
What is Medicare Hospice coverage
300
This system determines the payment amount for a particular service based on the classification system of that service
What is Medicare's Prospective Payment System
300
These codes are maintained and copyrighted by the American Medical Association (AMA). Providers use these codes to report services performed to payers for reimbursement purposes
What is Current Procedural Terminology
400
During this phase the case manager prepares the client for discharge or transfer to another provider. This puts the client at increased risk for adverse events
What is Transition of Care
400
These type of disability insurances only covers a portion of wages, typically 50-70%, and begin after a waiting period.
What is Short Term Disability and Long Term Disability
400
It is a health insurance program funded by both the state and federal government for individuals with limited income and resources
What is Medicaid
400
These are four Medicare Prospective Payment Systems
What is the Home Health Resource Group (HHRG, Case Mix Group (CMG), Resource Utilization Group (RUG), and Ambulatory Payment Classification System. (APC)
400
Medicare uses this system as a basis of payment for hospital inpatient services. In attempt to control costs, hospitals are paid based on this for the admission rather than each procedure performed or inpatient day
What is Diagnosis Related Group (DRG)
500
The process that consists of Screening, Stratifying Risk, Assessing, Planning, Implementing (care coordination), Follow-up, Transitioning, Communication post-transition, and Evaluation.
What is the Case Management Process
500
This prevents double payment for services when a subscriber has coverage from two or more sources.
What is Coordination of Benefits
500
This is a need-based program that makes case assistance payments to disabled individuals with limited income and resources. This is financed by general revenues collected by the Treasury Department
What is Supplemental Security Income
500
This uses quality measures that hospitals already report to Medicare via the Hospital Inpatient Quality Reporting Program.
What is Value-Based Purchasing
500
The official classification and listing of mental disorders. This includes the DSM-5, the older ICD-9, and has the ICD-10 codes
What is Diagnostic and Statistical manual of Mental Disorders (DSM)