Utilization management refers to procedures implemented to
Manage utilization of health care services.
The stages of the billing process include:
Services and items are provided and recorded in the patient's medical record and coded.
Utilization management procedures are implemented by various health care payers to:
Offer comprehensive health care services to members, cost efficiently
An organization consisting of a network of providers that are organized within a health system to offer patients a full range of managed health services is a(n):
Integrated Delivery System
A review conducted by a physician where all records pertinent to the patient stay are reviewed within a specified period after the patient is discharged, to determine if the care provided during the inpatient stay was appropriate based on the patient's diagnosis, is called the:
Utilization review process
A primary care network is:
Network of physicians, hospitals, and other providers integrated within a health care delivery system organized to provide health care services to patients.
A not-for-profit organization is one that:
Is formed for the purpose of providing some service that is designed to benefit the community.
Creation of the Department of Health, Education and Welfare (HEW), Occupational Safety and Health Act (OSHA), The Privacy Act, and the Patient Self-Determination Act (PSDA) are legislative actions designed to address
Issues related to the health, education, and welfare of the public
The department that is responsible for facilities and services provided to veterans of the U.S. Armed Services
Department of Veterans Affairs
Minimum state licensing requirements indicate hospitals must have this organized group, to whom the governing authority delegates responsibility for maintaining proper standards for medical and other health care. This requirement pertains to:
The government's influence on health care expanded with the creation of what programs?
Medicare and Medicaid
List three focus areas of governmental responsibility related to health care.
Quality of patient care, improve public health, and control health care costs
The mission of this state regulatory agency includes promoting public health and health and safety of all state residents through disease prevention and ensuring quality medical care is provided.
Department of Health
Minimum licensing requirements include provisions that state hospitals must have at least one the following
Four federal regulatory agencies involved in the regulation of health care in hospitals are:
Department of Health and Human Services, Department of Veterans Affairs, Department of Defense, and Department of Labor
When are hospitals allowed to bill for physician services provided in a hospital-based clinic?
When the physician is employed by the hospital
Hospital functions are generally categorized according to a grouping of specific tasks that highlight the following four major areas:
Administrative, financial, operational, and clinical
Hospitals maintain an inventory of rooms available in the hospital that patients are assigned to as they are admitted. The inventory is called
Hospitals bill for this portion of services when patients are seen in the Emergency Department by a physician who is not employed by or under contract with the hospital.
Care provided to a patient who is admitted on an inpatient basis is ordered by the:
When billing for ambulatory surgery services, the hospital bills for which portion of services?