Healthcare System and Policy Flashcards
7 cards from real CPE 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 System and Policy flashcards as text
The 'two-midnight rule' issued by CMS affects hospital reimbursement by:
Answer: Presuming inpatient admission is appropriate when a physician expects a patient to stay at least two midnights
The two-midnight rule establishes that CMS will generally presume inpatient admission is appropriate when the physician expects the patient to require care spanning two midnights.
Social determinants of health (SDOH) are increasingly integrated into value-based care models primarily because:
Answer: They significantly influence health outcomes and healthcare utilization patterns
SDOH (housing, food security, transportation, etc.) account for a substantial share of health outcomes and drive preventable utilization when unaddressed.
Under the No Surprises Act (2022), patients receiving out-of-network emergency care are generally responsible for no more than:
Answer: Their in-network cost-sharing amounts
The No Surprises Act protects patients from balance billing by limiting their liability to in-network cost-sharing for most surprise out-of-network bills.
A physician executive evaluating a proposed merger between two large hospital systems must consider antitrust implications under which federal law?
Answer: The Clayton Act and Hart-Scott-Rodino Act
The Clayton Act prohibits mergers that substantially lessen competition, and the Hart-Scott-Rodino Act requires pre-merger notification to the FTC and DOJ for transactions above certain thresholds.
The Medical Loss Ratio (MLR) requirement under the ACA mandates that insurers in the individual/small-group market spend at least what percentage of premium revenue on medical care and quality improvement?
Answer: 80%
The ACA requires insurers in the individual and small-group markets to maintain an MLR of at least 80%, meaning no more than 20% can go to administrative costs and profit.
When evaluating a capitated contract, a physician executive should be MOST concerned about which financial risk?
Answer: Adverse selection leading to a sicker-than-expected enrolled population
Under capitation, if the enrolled population is sicker than the capitation rate assumed, the provider bears the full financial loss from higher-than-expected utilization.
The Disproportionate Share Hospital (DSH) program provides additional Medicare and Medicaid payments to hospitals that:
Answer: Serve a high proportion of low-income and uninsured patients
DSH payments compensate hospitals for the uncompensated care costs associated with serving a high percentage of Medicaid and uninsured patients.