CPHIMS CPHIMS Healthcare Environment Fundamentals 5 — Questions and Answers
Question 1: In the US healthcare system, a 'never event' as defined by the National Quality Forum refers to:
- A medical procedure that has never been approved by the FDA
- A serious, largely preventable patient safety event that should never occur in a healthcare setting (Correct answer)
- A diagnosis code that cannot be assigned to an inpatient stay
- An insurance claim that is automatically denied on first submission
Correct answer: A serious, largely preventable patient safety event that should never occur in a healthcare setting
NQF defines 'never events' as serious reportable events that are unambiguous, serious, usually preventable, and of concern to the public and healthcare providers.
Question 2: The Stark Law (Physician Self-Referral Law) prohibits physicians from referring patients to entities with which they have a financial relationship for which of the following services?
- Primary care office visits
- Designated health services covered by Medicare or Medicaid (Correct answer)
- Any service provided in a foreign country
- Telemedicine consultations only
Correct answer: Designated health services covered by Medicare or Medicaid
The Stark Law prohibits physician self-referrals to entities in which they have a financial interest for any of 11 'designated health services' billable to Medicare or Medicaid.
Question 3: Which of the following best describes the role of an Integrated Delivery Network (IDN) in healthcare?
- A federal agency that integrates Medicare and Medicaid billing
- A coordinated network of providers and facilities under common ownership offering a continuum of care (Correct answer)
- A software platform that integrates multiple EHR systems
- A group of unaffiliated hospitals that share administrative staff
Correct answer: A coordinated network of providers and facilities under common ownership offering a continuum of care
An IDN is a single organization or system under common ownership that provides a full spectrum of care—from primary to acute to post-acute—often including its own health plan.
Question 4: The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals by reducing Medicare payments when readmission rates exceed expected levels for which type of readmissions?
- All readmissions within 180 days for any diagnosis
- Unplanned 30-day readmissions for specified conditions such as heart failure and pneumonia (Correct answer)
- Planned surgical readmissions for post-operative care
- Readmissions from nursing homes to acute care hospitals only
Correct answer: Unplanned 30-day readmissions for specified conditions such as heart failure and pneumonia
HRRP reduces Medicare payments to hospitals with excess unplanned 30-day readmission rates for specified conditions including heart failure, AMI, pneumonia, COPD, hip/knee arthroplasty, and CABG.
Question 5: In healthcare accreditation, what is the primary purpose of a 'tracer methodology' used by The Joint Commission during surveys?
- To electronically track medication dispensing in real time
- To follow individual patient care experiences through the organization to assess compliance with standards (Correct answer)
- To audit financial transactions across multiple departments
- To trace the physical movement of medical equipment for safety checks
Correct answer: To follow individual patient care experiences through the organization to assess compliance with standards
Tracer methodology follows an actual patient's care experience through multiple departments and staff interactions to evaluate compliance with Joint Commission standards in real-world care delivery.
Question 6: What does the term 'payer mix' represent in a hospital's financial context?
- The variety of health insurance products offered to hospital employees
- The distribution of patient revenue sources (Medicare, Medicaid, commercial, self-pay) in a given period (Correct answer)
- The combination of inpatient and outpatient services billed each month
- The ratio of fixed to variable costs in the hospital's operating budget
Correct answer: The distribution of patient revenue sources (Medicare, Medicaid, commercial, self-pay) in a given period
Payer mix describes the proportion of revenue or patient volume attributable to each payment source, which directly affects a hospital's overall reimbursement rates and financial health.
Question 7: Under the ACA's Medicaid expansion, states that opted in extended Medicaid eligibility to adults with incomes up to what percentage of the federal poverty level (FPL)?
- 100% FPL
- 133% FPL (effectively 138% with the income disregard) (Correct answer)
- 200% FPL
- 250% FPL
Correct answer: 133% FPL (effectively 138% with the income disregard)
The ACA expanded Medicaid to non-elderly adults with incomes up to 133% FPL, and with the standard 5% income disregard, the effective threshold is 138% FPL.
CPHIMS CPHIMS Healthcare Environment Fundamentals 5
In the US healthcare system, a 'never event' as defined by the National Quality Forum refers to: