Healthcare Systems and Operations Flashcards
7 cards from real TRIVIUM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Healthcare Systems and Operations flashcards as text
What is the primary function of a hospital's compliance program?
Answer: Preventing, detecting, and correcting violations of laws and regulations
A hospital compliance program establishes policies, training, and monitoring systems to ensure the organization adheres to applicable laws, regulations, and ethical standards.
Which concept describes the total cost a patient pays for covered services under an insurance plan before the plan begins to pay 100%?
Answer: Out-of-pocket maximum
The out-of-pocket maximum is the most a patient will pay for covered services in a plan year; after reaching it, the insurance pays 100% of covered costs.
What is a 'accountable care organization' (ACO) in the U.S. healthcare system?
Answer: A group of providers who voluntarily coordinate care for a patient population and share in savings
An ACO is a network of doctors, hospitals, and other providers who work together to deliver coordinated, high-quality care and share in savings generated for Medicare.
What does the term 'scope of practice' define for healthcare workers?
Answer: The procedures, actions, and processes a healthcare professional is permitted to perform based on training and licensure
Scope of practice defines the procedures and responsibilities that a licensed healthcare professional is legally authorized to perform based on their education, experience, and licensure.
In healthcare revenue cycle management, what is the 'clean claim' rate?
Answer: The proportion of claims submitted without errors that can be processed for payment immediately
The clean claim rate measures the percentage of claims that are submitted correctly the first time and do not require additional information before processing.
Which federal law protects employees who report healthcare fraud and abuse from employer retaliation?
Answer: False Claims Act whistleblower provisions
The False Claims Act includes whistleblower (qui tam) provisions that protect employees from retaliation when they report fraud against federal healthcare programs.
What is 'case management' in a healthcare setting?
Answer: A collaborative process of assessment, planning, and coordination of services to meet a patient's health needs
Case management involves a care coordinator working with patients, families, and providers to develop and implement a care plan that addresses clinical and social needs efficiently.