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A “business associate” is a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. ¹ Additional details on features of federal Medicaid managed care authorities are available here.. Show Result. b. Empirical studies show little evidence that managed care quality was lower than that found in fee-for-service plans. Describe the key steps in developing a modern quality management program. With these plans, the insurer signs contracts with certain health care providers and facilities to provide care for their members at a reduced cost. This concept addresses the MCO’s decisions relative to coverage sought by its members. A. Physicians should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion. You are a community nurse visiting a client from Venezuela who lives in rural Montana. This concept addresses the MCO’s decisions relative to coverage sought by its members. C. The insurer would pay … Drug utilization review (DUR) is defined as an authorized, structured, ongoing review of prescribing, dispensing and use of medication. Patients who belong to a managed care health plan, such as an HMO, are responsible for a small per-visit fee collected at the time of the visit. 2.14) Mrs. J. has just seen her provider. Background: Survey studies have shown that physicians believe managed care is having significant impact on many of their professional obligations. Back. Case managers do not use the nursing process. d) Tertiary care: Term. 107 Cards in this Set. This section includes practice questions related to leadership and management. You are planning to store 10 years' worth of records, and the average discharge rate is 2,500 per year. Front. Information sources are readily identifiable and under the control of the organization. Individuals pay taxes throughout their working lives and generally become eligible for Medicare when they reach age 65. C. Projects should focus on medical errors. Ethics, in general, are the moral principles that dictate how a person will conduct themselves. 6. All of the following fundamentals describe the characteristics associated with transcultural nursing except: Definition. Front. This creates a lack of privacy in regards to individual medical issues or concerns that take place. 111-148, as amended) made a number of changes to Medicaid. c. Managed care focuses on the ability to pay. The ambulance personnel, following established procedure, asked if he had chest pain. Questions and Answers. The following is intended to provide some general guidance on the statute, the regulations which implement it, and the reported cases which interpret it. Give the insured an unlimited choice of providers C. Coordinate benefits D. Control health insurance claims expenses A. The goal of a managed care system is to keep the costs of health care as low as possible without sacrificing the quality of the care that is given. This is done by creating a network of providers that can provide care and referrals whenever there is a health need which needs to be addressed. Which of the following statements about managed care are true? DUR encompasses a drug review against predetermined criteria that results in changes to drug therapy when these criteria are not met. The most common health plans available today often include features of managed care. What Is a “Business Associate?”. The origins of managed care can be traced back to at least 1929, when Michael Shadid, a physician in Elk City, Oklahoma, established a health cooperative for farmers in a small community without medical specialists or a nearby general hospital. A. Note that another frequently-used acronym, HSA, does not refer to a type of managed care. A member of the covered entity’s workforce is not a business associate. This means you have to solve the equation step by step, coming to the solution, which should be the same as in the statement. C. Cats have a genetic mutation of the ABCG2 blood retinal barrier transporter protein that permits diazepam to enter the aqueous humor, where it exerts a unique ocular toxicity in cats. The insurer would pay $4,440, and Crystal would pay $2,960. The managed care plan that allows plan members to go outside of the plan’s network to see health care providers. Information technology implementation is required to efficiently start patient safety projects. Family and Medical Leave Act b. •Identify and study best-of-class organizations. Managed care organizations receive summaries of a patient’s medical file as part of the treatment planning and payment process. As she pays her co-payment, she says "Oh dear, the doctor told me to see someone, but I can't remember what he said. Specialty Pharmacy J. Industry/Manufacturing. This fee is commonly called a(n) ____. B. approved by the primary care physician. fees and controlling patients ? d) tertiary care. A. d. Empirical evidence suggests that managed care fails to reduce health care spending. precertification. 7. D.PPOs are a common type of managed health care. A. The following is a list of certain key issues with respect to the MCO’s relationship with its members: Access To Care. Provide quality health care while containing costs. 1. Twice daily C. Three times daily D. Four times daily. A group of healthcare organizations that collectively provides a full range of coordinated health-related services. continue getting care no longer considered medically reasonable or necessary, you must issue the notice before the patient gets the non-covered care in order to transfer financial liability. This is a suitable form of contraception for women with recurrent urinary tract infection. A person's orientation B. The insurance company believes that T misrepresented his actual health on the initial insurance application and is, therefore, disputing the claim's validity. It has become the predominant system of delivering and receiving American health care since its implementation … 4. D. Involvement of the medical staff is critical in all patient safety projects. d. 2. With these plans, the insurer signs contracts with certain health care providers and facilities to provide care for their members at a reduced cost. The value-based care model ties medical payments to the quality of care provided (like not being readmitted to the hospital within a certain time frame). Adverse selection. There is a loss of privacy. The intent of managed health care was to. 3 APNs build on the competence of the RN skill set and demonstrate a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and significant role autonomy. A. B) The care of the patient is carefully planned and monitored by the primary care provider. Then it will tell you to do a proof. Chapter 12. c) secondary care. 2. There is a loss of privacy. Covered entities include health care providers, health plans, and health care clearinghouses. Answer: b. The department has planned for units that are five shelves high, and each shelf is to be 45 inches wide and have 40 inches of actual filing space. c. That information is a valuable resource that must be managed no matter what form it takes. prior authorization for hospital admission and some outpatient and in-office. access to expensive healthcare services through the utilization of HMOs , PPOs and POSs . Term. Select all that apply. Back. D. Which of the following statements best describes past efforts to develop vaccines for coronaviruses? HSA stands for health savings account, and HSA-qualified plans can be HMOs, PPOs, EPOs, or POS plans. The client is a diabetic and is hypertensive. Question options: Clinical model Role performance model Adaptive model Eudaimonistic model The clinical model of health views the absence of signs and … The principle objective of the medical profession is to render service to humanity with full respect for the dignity of man. B. Definition. 33. C. Both the nursing process and the nursing care plan are purely critical thinking strategies. B. For the HHCCN, the POC ends when an HHA stops delivering all services. Perhaps the most widely discussed is the expansion of eligibility to adults with incomes up to 133 percent of the federal poverty level (FPL). the managed care plan that is allowed to contract directly with employers to provide health care services is the: physician-hospital organization. B. The person chooses a primary care physician to manage the person B. HMOs are a common type of managed health care. Hosted by the American Counseling Association’s 70th president Dr. S Kent Butler, each 50-minute episode features special guests in conversation about topics relevant to the professional work and identity of counselors, the business of counseling, and mental health care. C. Replace fee- for-service plans with affordable, quality care to healthcare consumers. •Define indicators to measure performance. A health maintenance organization (HMO) is a form of health care that provides services for a fixed period on a prepaid basis. Which of the following is true for managed care health insurance plans? c. It lowers cost through the elimination of waste and excess. Most of managed care's savings do not affect hospitalization. 11The Clinton administration's proposed Health Security Act (HSA, 1993) gives appreciable attention to information systems and related matters. A child who does not undergo surgery due to the parents' religious beliefs according to a bona fide religion C. A parent who provides inadequate clothing due to reasons beyond the control of the parent D. A teacher who engages in nonconsensual sexual … FNP 590 Midterm and Finals Questions with Answers and Explanations. Fixed-price reimbursement is a feature of managed care. Which of the following statements accurately describes the clinical nurse leader (CNL)? B) manages the price paid for services. A managed care plan’s contractual responsibilities generally include the following key requirements: Network development and maintenance. Score 1 User: Combining two or more segments of the industry to deliver the best care, at the most cost … Use of knowledge and measurement tools to inform improvement. Which of the following phrases is characteristic of case management as a method of healthcare delivery? Insurance License Texas Life and Health Paper 29. The term used to describe sophisticated and highly complex medical care is... a) managed care. Critique this statement: The health record documents services provided by allied health professionals and a patient’s family. For the following statements, please indicate whether the medication use system / health record that is available to ... o Transitional ICU means that a private attending and an intensivist provide co-managed care of ICU patients. A physician suspects that his patient , Mr. Jones, may have bladder cancer. F) Planning and monitoring are conducted to ensure standards are followed. In addition, there are many different types of data on managed care programs including encounter data, enrollment data, and program information. This creates challenges for analyzing and monitoring managed care programs and limits the ability to compare states. Provide for the continuation of coverage when an employee leaves the plan B. d. is a health cost assistance program: A patient's diagnosis as established by the physician ____. Managed care organizations combine health insurance with the delivery of healthcare services to keep costs low and provide quality care. The federal government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP) . The traditional fee-for-service program offered directly through the federal government. The Patient Protection and Affordable Care Act (ACA, P.L. Annual physical Immunization shots as required Age related preventative treatment Managed Care is a health care delivery system organized to manage cost, utilization, and quality. Sixteen hour/day counselor ability Medically-Managed Intensive Inpatient 4 24 hour nursing care and daily physician care for severe, unstable problems in Dimensions 1, 2 or 3. Which of the following statements accurately describe an aspect of managed care? Statements that describe activities and attributes of nurses in this Code of Ethics are to be understood as normative or prescriptive statements expressing expectations of ethical behavior. C. After insertion, the cervix should be smoothly covered. A proof in calculus is when it will make a statement, such as: If y=cos3x, then y'''=18sin3x. Managed care plans are health insurance plans with the goal of managing two major aspects of healthcare: cost and quality. The managed care plan that is allowed to contract directly with employers to provide health care services is the: ... What are two statements that describe the standards for specialists physicians? The Code of Ethics for Nurses uses the term patient to refer to recipients of nursing care. Which statement best describes a psychotherapist’s goal of avoiding all dual relationships? It attempts to control costs by modifying the behavior of providers and patients. ... Pharmacy/Chain C. Hospital/Health Systems D. Administrative/Pharmacy Director E. Critical Care Pharmacy F. Long-term Care G. Managed Care/PBM H. Oncology I. The term “managed care” is used to describe a type of health care focused on helping to reduce costs, while keeping quality of care high. These include provider networks, provider oversight, prescription drug tiers, and more. Leadership is the ability to direct or motivate an individual or group to achieve set goals. C) has the objective of only providing those services that are necessary to contain costs. Wrong - Your answer is wrong. A situation in which only higher-risk employees choose and use certain benefits under a flexible benefits plan provided by employers is referred to as _____. D) maintains a sustainable noncompetitive advantage. The managed care plan offered through private insurance companies. Standards of care describe the competency level of nursing care as described by the ANA. “Transgender” describes a person's gender D. They can all describe either a person's orientation or … The derivation of this word The following is a list of certain key issues with respect to the MCO’s relationship with its members: Access To Care. The Nurse Practice Act regulates the licensing and practice of nursing; it describes the scope of practice. c. That information is a valuable resource that must be managed no matter what form it takes. This is a false statement as the health record only document’s physician’s care. The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care ("managed care techniques"). The origins of managed care can be traced back to at least 1929, when Michael Shadid, a physician in Elk City, Oklahoma, established a health cooperative for farmers in a small community without medical specialists or a nearby general hospital. Term. Which of the following statements accurately describe an aspect of managed care? Formal statement written and signed while a person is mentally competent that specifies how the person wishes to have his or her own death handled in the event that the person cannot participate in the decision making a. Which of these statements best describes oritavancin when formulated as Kimyrsa? The Marketing guidelines reflect CMS' interpretation of the marketing requirements and related provisions of the Medicare Advantage and Medicare Prescription Drug Benefit rules (Chapter 42 of the Code of Federal Regulations, Parts 422 and 423). b. Financial Management. All of the following are characteristics of PPOs except: A) flexibility B) managed health care C) limited physician choice D) fixed fee medical services View Answer It calls for the establishment … A person's gender C. The first three describe a person's orientation. Lecture(s)/Slide(s): d13-18. Medicare was established in 1965 under Title XVIII of the Social Security Act as a federal health insurance program for individuals age 65 and older, regardless of income or health status. 2. The EOB is generated when your provider submits a claim for the services you received. In outbreaks reported from acute care settings in the U.S. following implementation of universal masking, unmasked exposures to other health care workers were frequently implicated. "negotiate lower price". •Identify processes and outcomes that meet customer needs. cultures tend to be unstable. Members who choose outside providers will be billed a deductible and higher co-payment to reflect the physician’s fees. The MCO, PIHP, or PAHP must continue the enrollee's benefits if all of the following occur: ( 1) The enrollee files the request for an appeal timely in accordance with § 438.402 (c) (1) (ii) and (c) (2) (ii); ( 2) The appeal involves the termination, suspension, or reduction of … c. This is a false statement as the health record only documents care provided by patient families. This procedure is called a (n): The data that states send to CDC contains patient identifiers (true/false) False. d. All of the above. The increase in average life expectancy in the U.S. since 1900, about 30 years, is primarily due to public health initiatives. The insurer would pay $2,880, and Crystal would pay $4,320. The Point of Service (POS) managed healthcare system has characteristics of both HMOs and PPOs. The following are examples of hospital joint ventures that are unlikely to raise significant antitrust concerns. D. The quality assurance committee should direct all patient safety efforts. From a sampling of records in the current files, you have determined that the average thickness of each record is 2 inches. Weegy: In managed care, all services must be monitored and approved. Control Access to Providers (For Buyers): (a) Encourage members to use specified Providers (Participants/Buyers) and (in-network) (b) Controls costs by negotiating providers' fees. Which of the following best describes why pharmacists and pharmacy technicians should inquire as to the intended purpose of the animal when preparing a compounded prescription for an animal patient? The purpose of managed health care insurance plans is to A. Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for these … E) The managed care system may required approval for specialty care. Managed Care seemed to most authorities the best available answer. D. Cats have a renal portal elimination system whereby diazepam … 5. •Understand customer need. User: In managed care, all services must be A. monitored and approved. Select all that apply. Term. b) primary care. This creates a lack of privacy in regards to individual medical issues or concerns that take place. When in place, the woman is aware that the diaphragm fits snugly against the vaginal walls. A. Unlimited access to providers B. High-quality care C. Shared risk D. Preventive care A. Unlimited access to providers *There are five distinguishing features of managed care: controlled access to providers, comprehensive case management, risk sharing, preventive care, and high-quality care. b. A. 3. Direct clinical practice is a core competency of any APN role, although the actual skill set varies according to the needs of the patient population. a joint funding program by federal and state governments (excluding Arizona) for low-income patients on public assistance for their medical care. Correct - Your answer is correct. B. 1. Issuing an Advance Written Notice of Non-coverage When Multiple Entities Provide Care Management is to plan, organize, direct, and control available human, material, and financial resources to deliver quality care to patients and families. 2.13) Which of the following best describes the purpose of managed care? Dramatically improve the healthcare delivery system in the united states. copayment: Which of the following is a characteristic of Medicaid? According to the American Nurses Association (ANA), the nursing code of ethics is a guide for “carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.”. No one engaged in any part of health care delivery or planning today can fail to sense the immense changes on the horizon, even if the silhouettes of those changes, let alone the details, are in dispute. 20) Managed care can be described by all of the following except: A) manages the patient’s utilization of services. Methods: Primary care physicians were asked about the impact of managed care on: (1) physician-patient relationships, (2) the ability of physicians to carry out their professional ethical obligations, and (3) quality of patient … These providers and facilities all have to meet a minimum level of quality. Definition. a. Care/Practice Setting Highlights; Payor-based case manager: May implement the Case Management Process for a client upon direct contact via the telephone by the client/support system or upon referral from other professionals working for the payor organization such as a medical director, a claims adjuster, a clerical person, or a quality/performance improvement … C.Medicaid is a common type of managed health care. This is a true statement. The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care ("managed care techniques"). a. 26. 5. 4. Each is intended to demonstrate an aspect of the analysis that would be used to evaluate the venture. The state program that is comprised of Parts A, B, C, and D. Definition. The Medicaid program is jointly funded by the federal government and states. The insurance company sends you EOBs to help make clear: The cost of the care you received. Section 1. Section 2. All of the following are examples of managed care plans except. T files a claim on his Accident and Health policy after being treated for an illness. It has become the predominant system of delivering and receiving American health care since its implementation … B. It is a system that is based on patient and provider autonomy. Healthcare Delivery Systems. They allow people to go to any doctor they choose They are all preferred provider organizations They are required to provide free services to the poor They are designed to … A nursing process is written together with a nursing care plan. Which of the following is a characteristic of primary healthcare? Which of the following statements best describes an integrated delivery system? In risk-based managed care plans, states delegate responsibility to the MCO for creating and maintaining a … A person responsible for a child's welfare who uses physical force to remove a weapon from the child's possession B. Accreditation allows the facility, school, or hospital to operate and be recognized in good standing according to standards set by peers. To be eligible, a primary care physician must work in and have the ability to make referrals among the network providers. E. Resources are allocated to too many projects. A nursing care plan is a product of the nursing process. Managed care organizations are a: system in which financing, administration, and delivery of health care are linked to provide medical services to subscribers for a prepaid fee. A flexible benefits plan typically: Allows employees to select the benefits they prefer from options established by the employer. Of the following types of plans, costs for the patient are lowest, but choice of providers is most restricted, in a: *a. a. B. Which of the following antiretroviral therapy regimens should the pharmacist recommend for this patient? community bases trans cultural nursing. An EOB is a statement from your health insurance plan describing what costs it will cover for medical care or products you’ve received. b. Which of the following is an example of a confirming response to a patient? Health plans are entities that provide or pay the cost of medical care, such as private health insurers or managed care organizations, and governmental payors and health programs such as Medicaid, Medicare, or Veterans Affairs. If a claim was filed and $7,200 in costs remained after Crystal met the $200 deductible: A. Have employees of a managed care organization provide patient care. These providers and facilities all have to meet a minimum level of quality. In general, there are three levels of public health - local, state, and federal. Definition. Physicians are paid a flat per-member per-month fee for basic health care services, regardless of whether their services are used by the patient HMO's are heavily regulated by federal and state laws, which vary by state. Managed care organizations receive summaries of a patient’s medical file as part of the treatment planning and payment process. He wants to visually examine Mr. Jones' bladder. Select all that apply. Which of the following statements about the nursing process is true. Term. The words, “lesbian,” “gay,” “bisexual,” and “transgender” describe: A. Managed care plans are health insurance plans with the goal of managing two major aspects of healthcare: cost and quality. True. Which of the following statements is true concerning vaginal diaphragm use? The most common managed care financial arrangement, capitation, places healthcare providers in the role of micro-health insurers, assuming the responsibility for managing the unknown future health care costs of their patients. Small insurers, like individual consumers, tend to have annual costs that fluctuate far more than larger insurers. Each Managed Care Organization offered total health care for a predetermined monthly fee. Selected Answer : DRG Response Feedback : Managed Care Organizations , manage healthcare costs by negotiating discounted providers ? Select all that apply. Midterm Ch 1-8 Finals Ch 1-14, 25 CHAPTER 1 Which model of health is most likely used by a person who does not believe in preventive health care? Which of the following describes one of the elements that the nurse practitioner has successfully met? Health maintenance organizations Preferred provider organizations Indemnity arrangements Point-of-service plans. D. provided by the same physician. Once daily B. True. A. I … The creation of an opening of a portion of the colon through the abdominal wall to an outside surface is called a (n): Colostomy. Medically-Monitored Intensive Inpatient 3.7 24 hour nursing care with physician availability for significant problems in Dimensions 1, 2 or 3. Five Basic Characteristics of Managed Care Plan (1) 1. Objective(s): 4. Which of the following statements about managed health care is FALSE? C. billed at a fee-for-service rate. Following approval of the managed care state plan amendment or waiver, the federal government conducts oversight of states to ensure that they comply with the program accountability requirements and that states hold managed care plans accountable for the … The glomerular filtration rate in cats is considerably slower than it is in humans, resulting in a much longer half-life for diazepam.

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