Healthcare Analyst Systems & Regulations Flashcards

A hospital's case mix index (CMI) increased from 1.42 to 1.58 over one year. What does this most likely indicate?

Answer: Average patient acuity and resource consumption increased

A higher CMI indicates the hospital is treating more complex or resource-intensive cases on average, which typically correlates with higher reimbursement under DRG-based payment.

Under the ONC's United States Core Data for Interoperability (USCDI), which data class was added in version 2 to address social determinants of health?

Answer: Sexual Orientation and Gender Identity

USCDI v2 added Sexual Orientation and Gender Identity (SOGI) as a data class to better capture social and demographic factors affecting health equity.

Which federal law established the National Practitioner Data Bank (NPDB)?

Answer: Health Care Quality Improvement Act of 1986

The Health Care Quality Improvement Act of 1986 established the NPDB to collect and release information about adverse actions taken against healthcare practitioners.

In claims analytics, a 'flag' for potential duplicate billing would most likely be triggered by:

Answer: Two claims with the same patient, same date of service, same procedure code, and same provider

Duplicate billing flags are raised when identical claims—same patient, DOS, procedure, and provider—are submitted more than once, indicating potential overpayment.

The Medicare Physician Fee Schedule uses which unit to measure relative work, practice expense, and malpractice for each CPT code?

Answer: Relative Value Units (RVUs)

The Medicare Physician Fee Schedule calculates payments by multiplying Relative Value Units (RVUs) for work, practice expense, and malpractice by a conversion factor.

A healthcare analyst is validating data from a health information exchange (HIE). Which HL7 FHIR resource would contain a patient's list of active medications?

Answer: MedicationRequest

The FHIR MedicationRequest resource represents an order or request for medication, making it the appropriate resource for capturing active medication lists.

Under EMTALA, a hospital with an emergency department is required to provide a medical screening examination to:

Answer: Any individual who comes to the ED requesting examination or treatment

EMTALA requires participating hospitals to provide a medical screening exam to any individual who presents to the ED requesting examination, regardless of insurance status or ability to pay.