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CHAA Exam

Terms in this set (120)

Scatter Diagram
A graphic display of data plotted along two dimensions used to screen for a relationship between two variables
Run Chart
a visual display of data that enables monitoring of a process to determine whether there is a systemic change in process over time
Pareto Chart
A graphic representation of the frequency with which certain events occur may be used to set priorities or oppotunities for improvement
Measure
A number assigned to an object or event
Gantt Chart
A type of bar chart used in process or project planning and control to display planned work targets for completion of work in relation of time usually shows week month quarter
Just In Time
A method of ordering items as close to possible to their time of need
Clinical Pathway
management tool that organizes sequences and times the major intervention of the nursing staff physicians and other departments AKA care map; critical path
Histogram
a graphic display used to plot the frequency with which different valves of a given variables occur. Used to examine patterns
Algorithm
Recommended patient management strategies designed to direct decision making
Baseline
An observation or value that represents the background of measurable quanitity
Six Sigma
process improvement technique for blending organizational wisdom with proven statistical tools
Balanced Scorecard
strategic management system used to drive performance and accountability through the organization
Plan; Do; Check; Act;
AKA Deming or Shewart cycle
FOCUS
Find a process
Organize a team
Clarify Knowledge
Uncover the cause
Start Plan Do Act Check
5 major points of collection
Before service; At registration; During service; At Discharge; Collection follow-up
Standing Orders
Physician orders pre-established and approved for use by nurses under specific conditions in absence of the physician
Threshold
a level of achievement that determines the difference between what is deemed to be acceptable
Laws that Illinois House Healthcare Availability and Access Committee passed
1. the tax exempt hospital responsibility act- says that hospitals must use 8% of cost to provide care for poor
2. The fair Billing and Collection Practices Act-makes hospital quit aggressive ways to collect payments
Accepting Assignment
when a provider agrees to accept the allowable charges as full fee
Acute Care
the care is generally short term rather than chronic care
Assignment of Benefits AOB
Written authorization from the policyholder for the insurance company sends payment directly to providers
Adverse Selection
the tendency for those with impaired health status or who are prone to higher than average utilization of benefits to be enrolled in disproportionate numbers and lower deductible plans
Ambulatory Surgical Center
a freestanding facitlity other than a physician office where surgical and outpatient services take place
Acute Inpatient Care
generally short term less than 30 days
Add-ons
Patients who are scheduled for services less than 24 hours in advance of actual service time
Admission Authorization
the process of third party payor notification of urgent/emergent inpatient admission with specific time frame
3 steps of verbal communication
1. encoding-translating idea into words; 2. transmission-face to face or letter; 3. decoding-receiver must interpet the message
Communication Breakdown
38% is in your tone of voice; 6% is words; 55% body language
Patient Rights and Responsibilities
It is everyone's responsibility to know procedures; should be provided to patient unpon admission; must be in 12pts. writing and posted throughout
How customers complaints can be resloved
writing to the manager so they can follow up; obtain details; keep records; check to make sure that changes were made
Paralanguage
tone of voice volume and range of speech
Effective Listening Techniques
Hear them out; empathize with customer; apologize; take responsibility
Good Communication Tools
open ended questions; reflecting to find out what they understand; use examples; summarize
HIPPA
Health Insurance Portability Accountability Act 1996-
EMTALA
emergency medical treatment and active labor act-says no one can be discriminated against due to economic status
Statistical Reporting
provides summary of information for improvement
Clinical Data Repository CDR
provides ready access to information from a variety of sources within a healthcare network; the process of reviewing adjudicating and processing claims
Acute Care
patients who require a stay for several days requiring constant medical care
Adjusted patient days
yearly patient days adjusted by ratio of outpatient revenue to total revenue
Advance Beneficiary Notice ABN
(only in original medicare plan) notice given to beneficiary when Medicare is expected to deny payment
Aid to Families with Dependent Children (AFCD) used to be TANF
federal and state program that gives assitance to needy families. It is based on state's standards
Ambulatory Care
Mobile care given to patients that do not need to stay over night
All Patient Diagnosis Related Groups APDRG
how patients are processed for Medicare and Medicaid
Ancillary Services
in a hospital setting ex. lab work; x-rays/ services related to care
Assignment
agreement from physician saying they will bill Medicare directly and will accept their payment as full payment
Attending physician
Caregiver
Average Daily Census
the average of inpatients per day
Bundled Billing
AKA global package) combining all medical services into one bill ex. maternity care
Balanced Billing
If non-par.provider this makes you responsible for the difference between the amount paid by insurance
Centers For Medicare and Medicaid Services
agency within the U.S. Dept. of human services responsible for adminis. the Medicare and Medicaid progarm (formerly HCFA-healthcare financing Andministration
Wayfinding
signage system that directs patients and families where to go
Tricare/ Champva
healthcare program run by Dept. of Defense
Health Maintenance Organization
type of insurance that with certain health care providers using fixed fee structures or cap. rates
Preferred Provider Organization PPO
a panel of doctors hospitals or providers who work under the same umbrella to provide care
Guidelines for Auto insurance
with no insurance auto would be primary; if medicare or medicaid rep. and auto accident was result auto insurance would be primary *obtain claim #; verify benefits
Workers comp. Key information
Time and Date; type of injury; name of employee; and contact immediate supervisor; emp. ins. info;
Medicare Select
same as Medigap Insurance but it is like HMO; people must go to certain hospitals
Medicare + Choice
Must have A and B parts; Maybe able to get extra coverage like drug and extra days in the hospital; Medicare rights still apply
Medicaid
provides insurance to low income people; funded by state and federal govt.; states design program qual.; low income; aged blind or disable
Medigap Insurance
designed to help pay Medicare cost sharing amounts such as coinsurance and deductibles and uncovered services
Medicare Beneficary Notice MBN
monthly statement that list claims information
When Medicare is secondary payer
65 or older is covered by group health insurance which is provided by employer with more than 20 employees; below 65 disabled and member of household is working at employer with more than 100 employees covered by workers comp. patient has ESRD
Important Message from Medicare IMM
Lets beneficiaries know their rights provides # to PRO
Lifetime Reserve Days
Medicare will pay for an additional 60 days of hospitalization when stay is longer than 90 days
Tricare Prime
Like HMO
Tricare Extra
Like PPO saves money for patients
Payor Authorization
approval given from third party payors to provide spec. care
Pre-encounter communications
oral or written information shared with patients prior to arrival for service
Order entry
entering orders for clinical services into information systems
Departure
preparation and actual departure of patient from an encounter
Charge Capture
process of electronically or manually applying predetermined fees
Peer Review Organization PRO
Centers for Medicaid and Medicare services; designed to improve Medicare; national network has 53; Aka QIO
Relative Value Resource Based System RVRBS
paying doctors according to national fee schedule based on work and costs associated with each service
Diagnosis Related Group DRG
system where CMS began paying doctors a fixed rate per patient based on diagnosis
Fiscal Intermediaries FI
processes claims for Medicare Part A
Carriers
processes claims for Part B (Medicare)
Medicare
Federal health Insurance program; people 65 or older; people of any age with renal; certain disabled people under 65
Medicare Part A
pays for:hospital services inpatient skilled nursing services and hospice
Medicare Part C
private insurance company offering plans mostly to seniors (PPO or HMO)
Medicare Part B
pays for doctor services; outpatient hospital; medical equipment
Medicare Part D
helps cover medicines
Benefit Periods
begins on the first day of services if patient goes in a facility and ends 60 days after discharge as long as it is not interrupted by another facility; the # of days Medicare covers
Respite Care
short term care provided at home in a long term care facility not pai for by Medicare or Medicaid
Relative Value Scale
A list of procedure codes that uses units to indicate the relative value of medical services usually used in workers Comp.
Predetermination
An administrative procedure whereby a health provider submits a treatment plan
Recidivism
The frequency of the same patient being readmitted to the hospital for the same condition
Palliative Care
active total care of patients who have advanced illnesses no longer amenable to curative treatment control of symptoms is the focus
Outlier
one who does not fall within the norm a term typically used in utilization review. a provider who uses either too many or too few services
Open Access
a self referral arrangement allowing members to see participating providers for specialty care without a referral form AKA open panel
Non-availability Statement
a statement issued by a uniformed service hospital when medical care is not available at their institution and the patient must use civilan healthcare; if the patient lives outside the zip; doesn't need statement
Independent Practice Association IPA
health maintenance organization(HMO) delivery model in which the HMO contracts with physician organization
HCFA 1450
Medicare Part A claim form used for inpatients and outpatient encounters AKA UB92
Explaination of Benefits EOB
the statement sent to covered person by health plan listing services provided benefits paid on a claim; deductible and copayment
Evidence of Coverage EOC
an addendum of a group plan contract and constitutes only a summary of the terms and conditions of coverage
Consolidated Omnibus Budget Reconciliation Act COBRA
requries employers to permit employees/family to continue their group insurance coverage at their own expense
Comorbidity
a pre-exisiting condition that will because of its persence cause an increased stay in the hospital AkA substantial complication
Conservator
a person offical or institution designated to take over and protect the interests of an incompetent person
The Common Working File
a national file fo Medicare claims
Closed Access
a provision which specifies that plan members must obtain medical services only from PCP to get benefits
Clincal Integration
a type of operational integration that enables patients to receive a variety of health services from the same entity
Charge Description Master CDM
a master file in a computer system listing the services provided at the hospital that have an assigned charge
Case Mix Index CMI
determined by dividing the sum of all the DRG relative weights for every DRG used by Medicare patients by the total # of Medicare inpatient cases for the hospital
Centers for Disease Control and Prevention
one of the operating compoents of the Dept. Of health and human services; they monitor health; detect and investigate health problems; conduct research
Crave Out
a decision to separately purchase a service
Capitation
a fixed rate of payment to cover a specified set of health services
Authorization to Release Medical Information
the form authorizing releasing information from medical records to doctores hopitals or insurance
Batch processing
Information technology term referring to grouping similar input items and then processing them together
Opting out
meaning a confidentiality flag is placed into play so no visitors can enter patient's room
Healthcare Common Procedure Code Systems HCPCS
divided into 2 parts-1. CPT used to classify services provided by physicians, hospitals. and surgery centers; 2. non physician services
Patient Self Determination Act 1990
gives patients right to participate in their own healthcare
Notice of Privacy Practices NOPP
document that explains how protected information is used. this must be availiable to all patients
Ambulatory Services
patient receives surgical procedure and is released 4 to 6 hours after
Observation Care
treatment given to evaluate patient usually doesn't exceed 24 to 48 hours
Outpatient Care
treatment recieved for patient who is not hospitalized
Joint Commission
establishes national safety goals; evalutes environment education of staff and training
Tricare Standard
fee for service
Tricare for Life
Medicare eligible retirees Medicare eligible family members and widows certain former spouses; must have Part B
Coodination of Benefits
a way of determining the order in which benefits are paid
Birthday Rule
decides who is secondary and primary in the case of child that is covered by both parents insurance; whoevers birthday is 1st in the year they are primary
National Addociation of Insurance Commissioners NAIC
standardizes rules for COB
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