CPHIMS Healthcare Environment Fundamentals Flashcards

Which federal act established the conditions for participation that hospitals must meet to receive Medicare and Medicaid reimbursement?

Answer: Social Security Act

The Social Security Act established Conditions of Participation (CoPs) that healthcare organizations must meet to receive Medicare and Medicaid payments.

In the US healthcare system, what is the primary role of a Federally Qualified Health Center (FQHC)?

Answer: To offer comprehensive primary care to underserved populations regardless of ability to pay

FQHCs are community-based healthcare providers that receive federal funding to provide primary care services in underserved areas on a sliding-fee scale.

Which of the following best describes 'capitation' as a healthcare payment model?

Answer: Paying providers a fixed amount per enrolled patient per month regardless of services used

Capitation pays providers a predetermined monthly fee per patient, shifting financial risk to the provider regardless of how many services are actually delivered.

The Leapfrog Group is best known for which activity in the US healthcare environment?

Answer: Publicly reporting hospital safety and quality scores

The Leapfrog Group is an employer-driven coalition that publicly reports hospital performance data to improve transparency, safety, and quality.

Under value-based purchasing (VBP), Medicare withholds a percentage of DRG payments and redistributes them based on what?

Answer: Performance scores on quality and patient experience measures

CMS withholds a portion of base DRG payments and returns them—potentially with bonuses—based on hospitals' Total Performance Scores across multiple quality domains.

Which organization publishes the ICD-10-CM diagnosis coding system used in US clinical documentation?

Answer: Centers for Medicare & Medicaid Services and CDC

ICD-10-CM is maintained and published jointly by CMS and the CDC's National Center for Health Statistics for use in US clinical settings.

A hospital's 'case mix index' (CMI) is significant in healthcare finance primarily because it:

Answer: Reflects the average relative weight of all patient cases and influences Medicare revenue

CMI represents the average DRG weight for a hospital's inpatient cases; a higher CMI indicates more complex cases and results in higher Medicare reimbursements.