Healthcare Administration & Management Flashcards

A medical director notices that physician documentation rates for Medicare Advantage patients fall significantly below CMS benchmark expectations. Which intervention most directly addresses this risk?

Answer: Launch a hierarchical condition category (HCC) coding education program

HCC coding education helps physicians accurately document diagnoses that drive risk-adjustment scores, aligning with CMS expectations.

Under the Stark Law, which arrangement is most likely to constitute a prohibited self-referral?

Answer: A physician referring Medicare patients to a lab in which she holds an ownership interest

Stark Law prohibits physicians from referring Medicare patients to entities in which they have a financial relationship, including ownership interests, absent a statutory exception.

A long-term care facility wants to reduce avoidable hospitalizations. Which evidence-based program is specifically designed to achieve this goal?

Answer: INTERACT (Interventions to Reduce Acute Care Transfers)

INTERACT is a quality improvement program with tools and protocols designed to identify, evaluate, and manage acute changes in condition before they require hospitalization.

A medical director is asked to evaluate a proposed incentive compensation plan for employed physicians. Which element is most essential to ensure compliance with Anti-Kickback Statute safe harbors?

Answer: Compensation set in advance and not based on the value of referrals

Anti-Kickback safe harbors for employment require that compensation be set in advance at fair market value and not reflect the volume or value of referrals.

Which metric is most appropriate for evaluating throughput efficiency in an emergency department?

Answer: Door-to-provider time

Door-to-provider time directly measures how quickly patients receive initial clinical evaluation, reflecting ED throughput efficiency.

A post-acute care facility is transitioning to value-based purchasing. Which financial model most closely aligns provider incentives with patient outcomes across an episode of care?

Answer: Bundled payment arrangement

Bundled payments assign a single prospective payment for an entire care episode, incentivizing all providers to coordinate care and manage costs while meeting quality benchmarks.

A medical director must address a pattern of after-hours call avoidance by several physicians. Which approach best balances accountability with professional standards?

Answer: Review the on-call policy with affected physicians, document expectations, and implement a performance improvement plan if behavior continues

A structured response—reviewing policy, documenting expectations, and escalating to a PIP—respects due process while holding physicians accountable.