HAC Healthcare Analyst Systems & Regulations 3 — Questions and Answers
Question 1: A hospital's case mix index (CMI) increased from 1.42 to 1.58 over one year. What does this most likely indicate?
- The hospital is treating less complex patients
- Average patient acuity and resource consumption increased (Correct answer)
- The hospital reduced elective procedures
- Coding errors caused incorrect DRG assignments
Correct 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.
Question 2: 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?
- Vital Signs
- Clinical Notes
- Sexual Orientation and Gender Identity (Correct answer)
- Health Insurance Information
Correct 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.
Question 3: Which federal law established the National Practitioner Data Bank (NPDB)?
- Health Care Quality Improvement Act of 1986 (Correct answer)
- HITECH Act of 2009
- Balanced Budget Act of 1997
- Social Security Act Title XVIII
Correct 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.
Question 4: In claims analytics, a 'flag' for potential duplicate billing would most likely be triggered by:
- Two claims with the same patient, same date of service, same procedure code, and same provider (Correct answer)
- A claim submitted more than 90 days after the date of service
- A claim with a primary and secondary diagnosis code
- Facility and professional claims submitted for the same encounter
Correct 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.
Question 5: The Medicare Physician Fee Schedule uses which unit to measure relative work, practice expense, and malpractice for each CPT code?
- DRG weights
- Relative Value Units (RVUs) (Correct answer)
- Ambulatory Payment Classifications (APCs)
- Resource Utilization Groups (RUGs)
Correct 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.
Question 6: 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?
- Condition
- MedicationRequest (Correct answer)
- Observation
- Procedure
Correct answer: MedicationRequest
The FHIR MedicationRequest resource represents an order or request for medication, making it the appropriate resource for capturing active medication lists.
Question 7: Under EMTALA, a hospital with an emergency department is required to provide a medical screening examination to:
- Only patients with Medicare or Medicaid insurance
- Any individual who comes to the ED requesting examination or treatment (Correct answer)
- Patients within a 10-mile service area of the hospital
- Only patients who present with life-threatening conditions
Correct 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.
HAC Healthcare Analyst Systems & Regulations 3
A hospital's case mix index (CMI) increased from 1.42 to 1.58 over one year.
What does this most likely indicate?