WGU D052--Navigating Care Across the Continuum
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1. Social Security Act gov- governs funding and requirements for Medicare,
erns what Medicaid, CHIP, and more.
2. HIPAA and the HITECH protect patient privacy, requiring healthcare orga-
Act protect what? nizations to implement measures to keep patient
records secure.
3. The False Claims Act makes it illegal to file a false claim for funds from
a federal program.
4. The Patient Protection implemented new requirements for insurance,
and Affordable Care Act Medicaid, and more.
implemented what?
5. The Drug Enforcement regulate the creation and distribution of medica-
Administration and the tion.
Food and Drug Adminis-
tration regulate what?
6. The Department of Fraud
Health and Human Ser-
vices and the Office
of the Inspector Gener-
al help protect against
what?.
7. True or False. Medicare True
and Medicaid regula-
tions occur at both state
and federal levels.
8. Occupational Safety and Workplace regulations
Health Administration
and the Equal Employ-
ment Opportunity Com-
mission oversee What??
regulations.
9. KNOW your shared de-
cision and patient cen-
, WGU D052--Navigating Care Across the Continuum
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tered models !! FOr this
class (from FB page)
10. Mike Armstrong Advocate for patient safety after having a blood
test mis-read that showed he had leukemia. Do-
nated over 15 million dollars to John Hopkins to
develop programs for patient safety and diagnos-
tic excellence.
11. Common reason for data criminal attacks (cyber attacks)
breaches of PHI
12. HIPAA security rule cov- PHI (electronic format) of medical records
ers what
13. When considering the FDA and DEA
regulatory requirements
for healthcare, which
agencies primarily over-
see the use of medica-
tion?
14. Medicare and Medicaid Medicare
focus on specific groups
of people. Individuals
over the age of 65 and
disabled individuals are
the current focus of
what?
15. Medicare = Federal coverage for people over 65, certain peo-
ple under 65 with disabilities and people of any
age with end stage renal disease
16. Medicaid = Cooperative federal and state healthcare cover-
age for low-income adults, pregnant women, and
children
17. Medicare part Part A-Hospital Insurance
Part A Part B-Medical Insurance
, WGU D052--Navigating Care Across the Continuum
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Part B Part C- Medicare Advantage (HMO includes
Part C A&B)
Part D Part D- Prescription Drug
18. Qualified Medicare Bene- Helps pay premiums, deductibles, coinsurance,
ficiary (QMB) Program: and copayments for Part A, Part B, or both pro-
grams
19. Specified Low-Income Helps pay Part B premiums
Medicare Beneficiary
(SLMB) Program:
20. Qualifying Individual (QI) Helps pay Part B premiums
Program:
21. Qualified Disabled Work- Pays the Part A premium for certain disabled and
ing Individual (QDWI) working beneficiaries who have disabilities
Program:
22. Medicare Part A helps Inpatient hospital care Ï Skilled nursing facility
cover what care Ï Hospice care Ï Home health care
23. Medicare Part B helps Services from doctors and other health care
cover what providers Ï Outpatient care Ï Home health care
Ï Durable medical equipment Ï Many preventive
services
24. Medicare Part C covers includes all benefits and services covered under
what Part A and Part B and may include extra benefits
and services for an extra cost.
25. Medicare part D covers helps cover the cost of Prescription drugs
26. Name other types of Private insurance coverage (such as group
healthcare coverage health plan or retiree coverage) Ï TRICARE Ï CO-
BRA Ï Workers' Compensation Ï Liability insurance
coverage
27. Bundled payments Bundle payments or episode payment models
(EPMs) are an alternative means of payment that
, WGU D052--Navigating Care Across the Continuum
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encourage organizations to coordinate services
to improve the efficiency of care. Bundled pay-
ments are negotiated by CMS and third-party
payors to identify the total allowable expenditures
(target price) for a specific group of services.
These payments are predetermined and agreed
upon by the payor and payee. If Medicare and
Medicaid billing is acceptable to the organization,
then bundled payment services are already es-
tablished.
28. Value based services Value-based services assist in keeping the cost
down. Organizations work to provide services
without exceeding the established cost. If possi-
ble, the organization will attempt to increase its
payment by providing less expensive services.
This has allowed organizations to work together
to form purchasing groups. Due to the discounts
received, organizational profitability is improved
29. TPA Third Party Administrator
30. Why are medical bills re- Rejections can occur for many reasons but usu-
jected by insurance? ally occur when there is not enough documenta-
tion to support the claim or when information is
misfiled in a chart.
31. Insurance Rejections error was caught early in the claim's lifecycle
and the claim won't be accepted into the system.
(Could be due to incorrect name, DOB, address,
ID# etc)
32. Insurance Denials The claim has been entered into the payer's sys-
tem for adjudication, was reviewed by their claim
department, and was denied.
33. How would you follow up Submit a corrected claim
on a denied claim?
34.
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