WGU D052 Navigating Care Across the Continuum Already Graded A

WGU D052 Navigating Care Across the Continuum Already Graded A 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