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Nurse Case Manager Test Questions With Accurate Answers
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(TPA) Third party administrator correct answer Organization that processes health claims and other business related functions of health plan 3 types of measurements of performance improvement correct answer
5 stages of change correct answer 1. Precontemplation
COB - Coordination of Benefits correct answer a program for determining which health insurer pays for services first when a beneficiary is covered by more than one health care plan. Primary or secondary insuracne Concurrent review correct answer review for medical necessity of tests and procedures ordered during an inpatient hospitalization. Another form of UR that tracks consumption of resources while IE is hospitalized Conflict resolution strategies correct answer 1)collaboration
Diagnosis correct answer System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay. Used by Centers for Medicare/Medicaid services (CMS) to pay hospitals. Dual Diagno correct answer the client with both substance abuse and another psychiatric illness Examples of hard savings: correct answer transfer to a lower level of care decrease in length of stay negotiation to a lower rate for a service change to an in-network provider Examples of soft savings: correct answer avoided hospital readmission prevention of medical complications avoided ER visits. Exclusive Provider Organization correct answer managed care plan that provides benefits only if care is rendered by providers w/in a specific network Fee fo correct answer Providers are paid for each service performed, as opposed to capitation. Fee schedules are an example of fee-for-service.
Inpatient Rehab correct answer Pt's must be able to tolerate 3hrs/day of therapy, 5-7 days/wk, and be medically stable. LTD- Long correct answer Portion of wage replaced waiting period (usually after STD ends) Covers non-work related injury/accident/illness premium paid by ER/IE/both ends at 65 Medicare HHC part A correct answer -Covers first 100 days following a 3 day hospitalization of SNF
NQF - N correct answer membership based organization designed to develop and implement a national strategy for healthcare quality measurement and reporting Outcome and assessment information correct answer A prospective nursing assessment instrument completed by home health agencies at the time the patient is entered for home health services. Scoring determines the Home Health Resource Group (HHRG) Outcome indicators correct answer Measures of quality and cost of care. Metrics used to examine and evaluate the results of the care delivered. Outcome Management correct answer The use of information and knowledge gained from outcomes monitoring to achieve optimal client outcomes through improved clinical decision making and service delivery. Outcome Monitoring correct answer repeated measurement over time of outcome indicators in a manner that permits causal inferences about which patient characteristics, care processes, and resources produced the observed patient outcomes. Outcomes Measurement correct answer systemic, quantitative observation, at a point in time, of outcome indicators
Performance improv correct answer The continuous study and adaptation of the functions and processes of a healthcare organization to increase the probability of achieving desired outcomes and to better meet the needs of patients. POS - Point of Service correct answer A plan, combining features of an HMO and a PPO, in which members may choose from providers in a primary or secondary network. PPO - correct answer A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan's network. Principle/Agent correct answer Doctor is agent employed by hospital (principal). Dr authorized to act on behalf of hospital but hospital is responsible. Principles of motivational interview correct answer 1) express empathy
risk sharing correct answer The process whereby an HMO and contracted provider each accept partial responsibility for the financial risk and rewards involved in cost-effectively caring for the members enrolled in the plan and assigned to a specific provider. SMART planning correct answer Specific Measurable Achievable Realistic Timely SSDI - social security disability income correct answer amount of benefit depended on work record 5-month waiting period can be approved more quickly for serious injury/illness covers a disability expecte to last 12 months or more funded by SS taxes paid by workers/employers/self employed At 65 turns into SS retirement benefit staff model HMO correct answer The most rigid HMO model. Physicians are on the staff of the HMO with some sort of salaried arrangement and provide care exclusively for the health plan enrollees.
STD - short term disab correct answer Portion of wage replaced waiting period - 7-30days from day of disability covers non-work injury/illness premium paid by ER/IE/both Ends 90-180 days after date of disability Stratifying Risk correct answer phase that determines the appropriate level of intervention by classifying the pt as low or high risk. Tools used to assess for hospice correct answer 1) Karnofsky Performance Scale (0-100%) Less than 70% = Hospice
individualized
