CPHIMS CPHIMS Healthcare Environment Fundamentals 3 — Questions and Answers
Question 1: Which piece of legislation created the Children's Health Insurance Program (CHIP) to provide coverage for uninsured children in families above Medicaid income limits?
- Balanced Budget Act of 1997 (Correct answer)
- Affordable Care Act of 2010
- HITECH Act of 2009
- Medicare Modernization Act of 2003
Correct answer: Balanced Budget Act of 1997
The Balanced Budget Act of 1997 established CHIP (originally SCHIP), extending health coverage to millions of children in low- to moderate-income families.
Question 2: In a Health Maintenance Organization (HMO), patients typically must:
- Choose any physician in the country without referrals
- Select a primary care physician and obtain referrals for specialist visits (Correct answer)
- Pay full cost of care and submit claims for reimbursement
- Enroll only if they are Medicare beneficiaries
Correct answer: Select a primary care physician and obtain referrals for specialist visits
HMOs require members to select a primary care physician (PCP) who acts as a gatekeeper and must provide referrals for specialist care within the network.
Question 3: The National Quality Forum (NQF) plays which role in the US healthcare quality landscape?
- Directly inspecting hospitals and issuing accreditation certificates
- Endorsing standardized performance measures used for public reporting and payment (Correct answer)
- Setting HIPAA privacy regulations for health information
- Certifying electronic health record systems for federal incentive programs
Correct answer: Endorsing standardized performance measures used for public reporting and payment
NQF is a nonprofit that endorses consensus-based performance measures used by CMS, accreditors, and health plans for quality reporting and value-based payment.
Question 4: What is the primary purpose of the Medicare Severity Diagnosis Related Group (MS-DRG) system?
- To rank hospitals by patient satisfaction scores
- To classify inpatient hospital cases into groups for standardized payment (Correct answer)
- To determine outpatient visit reimbursement under the physician fee schedule
- To assess nursing home quality for five-star ratings
Correct answer: To classify inpatient hospital cases into groups for standardized payment
MS-DRGs classify inpatient cases into clinically coherent groups with similar resource utilization to establish fixed prospective payment amounts for Medicare.
Question 5: A hospital that participates in a Pioneer Accountable Care Organization (ACO) model primarily aims to:
- Increase patient volume through aggressive marketing
- Improve care coordination and share in savings achieved below a spending benchmark (Correct answer)
- Negotiate higher commercial insurance rates
- Reduce nurse-to-patient ratios to cut operational costs
Correct answer: Improve care coordination and share in savings achieved below a spending benchmark
ACOs coordinate care for an assigned Medicare population and share in any savings when total spending falls below a set benchmark while meeting quality thresholds.
Question 6: Which regulatory body enforces HIPAA Privacy and Security Rules against covered entities?
- The Joint Commission
- Office for Civil Rights (OCR) within HHS (Correct answer)
- Centers for Medicare & Medicaid Services
- Food and Drug Administration
Correct answer: Office for Civil Rights (OCR) within HHS
The HHS Office for Civil Rights (OCR) is the federal agency responsible for enforcing HIPAA Privacy, Security, and Breach Notification Rules.
Question 7: In the context of US healthcare staffing, what does the term 'privileging' refer to?
- Granting physicians access to the EHR system
- Authorizing specific clinical procedures a provider may perform at a facility (Correct answer)
- Assigning nurses to high-acuity patient units
- Verifying a provider's insurance credentials for billing
Correct answer: Authorizing specific clinical procedures a provider may perform at a facility
Privileging is the process by which a healthcare organization authorizes a specific scope of patient care services a licensed practitioner may perform at that institution.
CPHIMS CPHIMS Healthcare Environment Fundamentals 3
Which piece of legislation created the Children's Health Insurance Program (CHIP) to provide coverage for uninsured children in families above Medicaid income limits?