Healthcare Systems & Administration Flashcards
7 cards from real ABPS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Healthcare Systems & Administration flashcards as text
What is the purpose of a formulary in a health insurance plan?
Answer: To list covered prescription drugs and their cost-sharing tiers
A formulary is a tiered list of covered medications that determines member cost-sharing and guides prescribing decisions within a health plan.
Which model of care delivery places a team of healthcare professionals responsible for all of a patient's care needs across settings?
Answer: Patient-Centered Medical Home (PCMH)
The PCMH model emphasizes comprehensive, coordinated, team-based care with a personal physician leading a care team across all health domains.
A 'sentinel event' in hospital quality management is defined as:
Answer: An unexpected occurrence involving death or serious physical or psychological injury
The Joint Commission defines a sentinel event as an unexpected incident causing death or serious harm, requiring immediate root cause analysis.
Under value-based purchasing (VBP), hospital payments are adjusted based on:
Answer: Performance on quality and patient experience measures
CMS's Hospital VBP program ties a portion of inpatient payments to performance on measures of clinical outcomes, safety, efficiency, and patient experience.
Which of the following is the primary function of a utilization review committee in a hospital?
Answer: Evaluating the appropriateness and medical necessity of services provided
Utilization review involves evaluating whether the services rendered are medically necessary and appropriate, preventing overuse and supporting payer authorization decisions.
The concept of 'bundled payments' in healthcare reimbursement means:
Answer: A single payment covering all services related to a specific treatment episode
Bundled payments provide a single reimbursement for all services (hospital, physician, post-acute) related to a defined episode, incentivizing coordination and efficiency.
Which law established the Children's Health Insurance Program (CHIP) to extend coverage to uninsured children in families with incomes too high for Medicaid?
Answer: Balanced Budget Act of 1997
CHIP was created by the Balanced Budget Act of 1997 as Title XXI of the Social Security Act, providing states with federal funds to cover low-income children not eligible for Medicaid.