CPHIMS CPHIMS Healthcare Environment Fundamentals 4 — Questions and Answers
Question 1: Which of the following is a characteristic of a Preferred Provider Organization (PPO) that distinguishes it from an HMO?
- Members must select a primary care physician gatekeeper
- Members can see out-of-network providers at higher cost without a referral (Correct answer)
- Coverage is only available for preventive services
- Premiums are always lower than HMO premiums
Correct answer: Members can see out-of-network providers at higher cost without a referral
PPOs allow members to visit out-of-network providers without a referral, though at a higher cost-sharing level than in-network care, providing greater flexibility than HMOs.
Question 2: The 'triple aim' framework developed by the Institute for Healthcare Improvement (IHI) includes improving population health, enhancing patient experience, AND:
- Increasing hospital market share
- Reducing per capita cost of care (Correct answer)
- Expanding the number of licensed providers
- Standardizing electronic health record platforms
Correct answer: Reducing per capita cost of care
IHI's Triple Aim framework focuses simultaneously on improving population health, enhancing patient experience of care, and reducing the per capita cost of healthcare.
Question 3: Under EMTALA (Emergency Medical Treatment and Labor Act), a hospital with an emergency department is required to:
- Provide free care to all uninsured patients
- Perform a medical screening examination for anyone seeking emergency care regardless of ability to pay (Correct answer)
- Accept all Medicare patients transferred from other hospitals
- Maintain a specialist on call 24 hours a day for every specialty
Correct answer: Perform a medical screening examination for anyone seeking emergency care regardless of ability to pay
EMTALA requires hospitals with emergency departments to provide a medical screening examination and stabilizing treatment to any individual regardless of their insurance or payment ability.
Question 4: Which entity is responsible for publishing and maintaining Current Procedural Terminology (CPT) codes?
- Centers for Medicare & Medicaid Services
- American Medical Association (Correct answer)
- American Health Information Management Association
- National Committee for Quality Assurance
Correct answer: American Medical Association
CPT codes are owned and maintained by the American Medical Association (AMA) and are used to describe medical, surgical, and diagnostic services for billing purposes.
Question 5: In healthcare, 'utilization management' primarily involves:
- Managing the physical space and equipment in clinical departments
- Reviewing the necessity, appropriateness, and efficiency of healthcare services (Correct answer)
- Tracking employee attendance and shift scheduling
- Auditing financial statements for regulatory compliance
Correct answer: Reviewing the necessity, appropriateness, and efficiency of healthcare services
Utilization management evaluates the medical necessity and appropriateness of healthcare services at various stages—before, during, and after care delivery—to ensure efficient resource use.
Question 6: What is the primary distinction between 'incidence' and 'prevalence' in epidemiology as applied to healthcare planning?
- Incidence measures total existing cases; prevalence measures new cases in a period
- Incidence measures new cases in a time period; prevalence measures total existing cases at a point in time (Correct answer)
- Both terms are interchangeable in healthcare informatics
- Incidence applies only to infectious diseases; prevalence applies to chronic conditions
Correct answer: Incidence measures new cases in a time period; prevalence measures total existing cases at a point in time
Incidence counts new cases occurring during a specific period, while prevalence counts all existing cases (new and old) at a particular point or over a period.
Question 7: A hospital seeking Magnet Recognition from the American Nurses Credentialing Center (ANCC) must demonstrate excellence in which domain?
- Electronic health record implementation only
- Nursing practice, leadership, and patient outcomes (Correct answer)
- Physician recruitment and retention strategies
- Financial sustainability and revenue cycle performance
Correct answer: Nursing practice, leadership, and patient outcomes
Magnet Recognition designates hospitals that demonstrate excellence in nursing practice, transformational leadership, structural empowerment, and superior patient outcomes.
CPHIMS CPHIMS Healthcare Environment Fundamentals 4
Which of the following is a characteristic of a Preferred Provider Organization (PPO) that distinguishes it from an HMO?