Healthcare Analyst Systems & Regulations Flashcards

Which measure type in HEDIS assesses whether a patient received a recommended preventive service within a specific time window?

Answer: Process measure

HEDIS process measures capture whether a clinically recommended service (e.g., mammogram, A1c test) was delivered within a defined time period, reflecting adherence to evidence-based care.

In SQL-based claims analysis, which JOIN type would return all claims from a member table even if no matching encounter record exists?

Answer: LEFT JOIN

A LEFT JOIN returns all rows from the left (member) table and matching rows from the right (encounter) table; unmatched members appear with NULL encounter fields.

The Stark Law (Physician Self-Referral Law) prohibits physicians from referring Medicare patients to entities for designated health services when the physician has a:

Answer: Financial relationship with the entity

The Stark Law prohibits self-referral when a physician (or immediate family member) has a financial relationship—ownership, investment, or compensation arrangement—with the referred entity.

A managed care organization wants to measure the percentage of members with diabetes who had an HbA1c test. Which data source is most reliable for this HEDIS measure?

Answer: Medical record review or administrative claims with lab data

HEDIS diabetes measures rely on administrative claims supplemented by lab data or medical record review to confirm HbA1c testing occurred during the measurement year.

Which law requires large employers (50+ full-time equivalents) to offer affordable health coverage or face a shared responsibility payment?

Answer: ACA Employer Shared Responsibility (Pay or Play)

The ACA's Employer Shared Responsibility provisions (IRC §4980H) require applicable large employers to offer minimum essential coverage or pay an assessable payment to the IRS.

In a hospital's revenue cycle, 'claim scrubbing' refers to the process of:

Answer: Automatically reviewing claims for errors before submission to payers

Claim scrubbing involves automated pre-submission edits that check for coding errors, missing data, and payer-specific rule violations to reduce denials and rework.

Which statistical concept describes the proportion of people with a disease who test positive on a screening test?

Answer: Sensitivity

Sensitivity (true positive rate) measures a test's ability to correctly identify individuals who have the disease—it is the proportion of true cases that are detected.