WGU D052 Navigating Care Across the Continuum | 325 Questions with 100% Correct Answers | Verified | Latest Update | 77 Pages
WGU D052 Navigating Care Across the
Continuum
When considering the regulatory requirements for healthcare, which agencies primarily oversee
the use of medication? – ✔✔FDA and DEA
The FDA (Federal Drug Administration) and DEA (Drug Enforcement Agency) focus on
medication compliance and medication utilization.
How would you follow up on a denied claim? – ✔✔Make sure resubmissions are marked as
“corrected claim” and include the reference number from the denied claim.
What information should you supply when you are calling to discuss a claim? – ✔✔Client’s date
of birth, the organization’s tax ID or NPI, info from the claim about date of service and coding,
how much is being billed.
What are the possible outcomes of the phone call that Barbara Griswold describes? – ✔✔A
corrected claim will need to be submitted, you may need to speak with a supervisor, or you may
need to file an appeal.
Which statement about the role of the healthcare services coordinator (HSC) is true? – ✔✔The
goal of the HCS is to improve the quality of client care and reimbursement practices through
accurate documentation and to assist the client to improve the quality of life across the
continuum of care.
The goal of care coordination is to improve the quality of care delivery and resource
management, ensure correct documentation is available for coding, and assist the client
throughout the continuum of care.
What do the terms HIPAA and PHI stand for? – ✔✔Health Insurance Portability; Accountability
Act and Personal Health Information
HIPPA and PHI are two areas where everyone is responsible for protecting the information for
the client.
When considering the regulatory requirements for healthcare, which agencies help protect
against fraud? – ✔✔The Department of Health and Human Services (DHHS) and the Office of
the Inspector General (OIG)
Which of the following is a valid comparison of Medicare versus Medicaid? – ✔✔Medicare is a
federal health care coverage program mainly for people over 65 and some people younger than
that who have disabilities, whereas Medicaid is a federal and state health care coverage program
for low-income adults, pregnant women, and children.
Medicare is a federal health care coverage program mainly for people over 65 and some people
younger than that who have disabilities, whereas Medicaid is a federal and state health care
coverage program for low-income adults, pregnant women, and children.
How do the reporting requirements for a sentinel event differ from those for a less serious health
outcome? – ✔✔Sentinal events are reportable to the government.
What insurance was available prior to the 1900’s? – ✔✔None
There was no insurance available prior to 1900 for most citizens.
Payment by an insured member, a share of the payment made against a claim – ✔✔Co-insurance
Fixed amount of money paid by the insured each time a service is rendered – ✔✔Co-payment
Fixed amount of money a member must pay each year before benefits are paid by insurance
company – ✔✔Deductible
Set amount paid to providers on the basis of per member, per month, regardless of amount of
services used – ✔✔Capitation
Who is the gatekeeper for a patient’s healthcare needs? – ✔✔General Practice Provider
The general practice provider can be an MD, FNP, PA or other medical oversight specialist
working with a provider.
Why is it important to know insurance regulations and requirements? – ✔✔The importance of
knowing insurance regulations and requirements is to deliver effective and efficient care in a
timely fashion while removing the burden of dealing with the insurance company from the
patient.
Which software company is considered the gold standard for providing care coordination? –
✔✔InterQual
What is the purpose of the Hospital Compare website? – ✔✔To provide information to
consumers about their local hospitals for comparison
The goal is to ensure that the customer has the ability to make an informed decision on the
facility in which they want to be cared for.
A team of coordinators is creating a clinical review process for patient paperwork to maximize
compliance with insurance regulations toward the goal of reducing claim denials. Which two
elements must be included within the review process? – ✔✔Cost containment and utilization
management
Clinical review processes must include both cost containment and utilization management to be
effective.
Which action will assist the coordinator in identifying areas where errors in patients’ insurance
paperwork are causing claim denials? – ✔✔Analyzing EHR data
Tracking and analyzing patient records will provide for the identification of problem areas where
processes can be adjusted.
Which coordinator’s task is aligned with reducing patient insurance costs? – ✔✔Arranging
patient preventive care services
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