Payment And Delivery Systems - Ccma
- What does a bundled payment (episode-based payment) reimburse?
- A single payment for all services in a defined episode of care. It consolidates costs for a specific treatment period, promoting efficiency and collaboration among providers.
- What is the main purpose of a Patient-Centered Medical Home (PCMH)?
- Provide coordinated, comprehensive, team-based primary care. PCMHs emphasize accessible, patient-focused care through multidisciplinary teams and continuous relationships.
- Which payment model most strongly incentivizes increasing service volume?
- Fee-for-service (FFS). FFS rewards higher service quantities, often without incentives for efficiency or quality.
- What is prior authorization (preauthorization)?
- Payer approval required before a service is covered. This process ensures services meet coverage criteria, preventing unnecessary expenditures.
- What is shared savings in an accountable care arrangement?
- Providers keep a portion of cost savings if quality targets are met. This mechanism allows providers to share in financial gains from efficient care while maintaining quality.
- Identify the best action to reduce readmissions after discharge as part of care coordination.
- Perform medication reconciliation and confirm follow-up appointment. These steps ensure medication accuracy and timely post-discharge monitoring to prevent complications.
- What is shared risk (downside risk) in value-based contracts?
- Providers may owe money if costs exceed targets or quality is poor. It imposes financial penalties on providers for exceeding budgets or failing quality benchmarks.
- What is a referral in managed care?
- Authorization for a patient to see a specialist or receive services. Referrals facilitate managed access to specialized care, controlling costs in certain plans.
- What is the key goal of value-based payment models?
- Pay for quality and outcomes rather than volume of services. These models tie reimbursement to measurable improvements in patient health and cost-effectiveness.
- What is a care transition?
- Movement of a patient between providers or settings (e.g., hospital to home). Transitions require careful planning to maintain care continuity and avoid adverse events.
- What is capitation in health care reimbursement?
- A fixed per-member-per-month payment regardless of services used. Providers receive a predetermined fee to cover all necessary care for enrolled patients, shifting risk from payers.
- What is the primary feature of a fee-for-service (FFS) payment model?
- Payment is made for each individual service provided. This model compensates providers per procedure or visit, potentially leading to overutilization without regard for outcomes.
- What is the definition of a health care network in managed care?
- A contracted group of providers and facilities for covered services. Networks limit choices to preferred providers, managing costs and quality in plans.
- Which option best describes medication reconciliation during a care transition?
- Compare all medication lists and resolve discrepancies. This process identifies and corrects errors in medication regimens during handoffs.
- What is the definition of coordination of care?
- Organizing patient care activities across people and settings. It ensures seamless information sharing and continuity across healthcare encounters.
- What is case management in a clinical setting?
- Coordinated planning and services for complex or high-risk patients. Case managers oversee tailored interventions to improve outcomes for vulnerable populations.
- What is disease management intended to address?
- Ongoing care for chronic conditions using evidence-based protocols. Programs apply structured approaches to prevent complications and reduce healthcare utilization.
- Which payment model most directly shifts financial risk to the provider?
- Capitation. Providers bear the financial burden if care costs exceed the fixed payment received.
- What is a pay-for-performance (P4P) model designed to do?
- Provide incentives based on meeting quality or efficiency metrics. It rewards providers financially for achieving predefined performance standards in care delivery.
- What does a quality measure typically evaluate in value-based care programs?
- Clinical outcomes, patient safety, patient experience, or process adherence. Metrics assess effectiveness in key areas to drive improvements in value-based systems.
- What is utilization management intended to control?
- Appropriateness, medical necessity, and cost of services. It reviews and optimizes resource use to ensure services are necessary and economical.
- Identify the best documentation to send with a referral to support coordinated care.
- Reason for referral, recent notes, labs/imaging, and medication list. Comprehensive records enable informed decision-making and continuity in specialist care.
- What is a key difference between an HMO and a PPO regarding out-of-network care?
- PPOs usually cover out-of-network care; HMOs typically do not. PPOs offer flexibility with partial coverage outside networks, unlike restrictive HMOs.
- What is the role of a primary care provider (PCP) in an HMO model?
- Acts as gatekeeper and coordinates referrals and care. PCPs manage overall health, authorizing specialist visits to streamline care in HMOs.