WGU D052 2024 UPDATE COMPREHENSIVE QUESTIONS
AND VERIFIED DETAILED ANSWERS NAVIGATING CARE
ACROSS THE CONTINUUM [GRADE A+]
When considering the regulatory requirements for healthcare, which agencies primarily
oversee the use of medication? - (correct answer) 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? - (correct answer) 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? -
(correct answer) 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? -
(correct answer) 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? -
(correct answer) 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? - (correct answer) 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? - (correct answer) 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? - (correct
answer) 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? - (correct answer) Sentinal events are reportable to the
government.
What insurance was available prior to the 1900's? - (correct answer) 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 -
(correct answer) Co-insurance
Fixed amount of money paid by the insured each time a service is rendered - (correct
answer) Co-payment
Fixed amount of money a member must pay each year before benefits are paid by
insurance company - (correct answer) Deductible
Set amount paid to providers on the basis of per member, per month, regardless of
amount of services used - (correct answer) Capitation
Who is the gatekeeper for a patient's healthcare needs? - (correct answer) 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? - (correct
answer) 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? - (correct answer) InterQual
What is the purpose of the Hospital Compare website? - (correct answer) 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? - (correct
answer) 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? - (correct answer) 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? - (correct
answer) Arranging patient preventive care services
Preventive care services have proven to reduce the need for medical services and
reduce patient insurance costs.
What are the six domains of care across which HEDIS collects more than 90
measures? - (correct answer) Effectiveness of Care
Access/Availability of Care
Experience of Care
Utilization and Risk-Adjusted Utilization
Health Plan Descriptive Information
Measures Collected Using Electronic Clinical Data Systems
How many goals are included in the Affordable Healthcare Act? - (correct answer) 3
The three goals are affordability, availability and cost containment.
What are the six quality improvement concepts discussed within the webpage? -
(correct answer) Establish a culture of quality
Determine and prioritize areas for improvement
Collect and analyze data
Communicate your results
Commit to ongoing evaluation
Spread your success
Healthcare needs innovative ways to improve care delivery and reduce costs. Identify
what the PDSA cycle means in relation to these healthcare objectives. - (correct
answer) A Process improvement cycle
Plan Do Study Act is a performance improvement cycle used in healthcare to improve
quality and cost analysis.
What are the three areas of value provided by Compass Training? - (correct answer)
Care Coordination
Utilization Management
Patient Transitions
What is the National Transitions of Care Standards Framework? - (correct answer)
Standards to help organizations assess, quantify, and identify gaps in current care
transition work plan
, This applies to all healthcare setting to foster effective, quality, and efficient practices in
transitional services.
What action would have broken the chain of infection? - (correct answer) Proper
hand hygiene
Why is it important to follow organizational policies? - (correct answer) Policy is a
written guideline that the organization and staff follow to guide practices and to meet
regulatory requirements.
Policies are based on the EBP guidelines established by the regulating agencies.
Why is certification important? - (correct answer) For identification of the knowledge
and experience in a chosen field
Certifications require a specific amount of experience and a knowledge and application
examination.
What is the whistleblower hotline number? - (correct answer) 1-800-HHS-TIPS (1-
800-447-8477)
What would you do if you suspected fraud is occurring? - (correct answer) call the
whistle blower hotline
This is an anonymous method for reporting that helps prevents retaliation.
Which of the following is a feature of the Affordable Care Act (ACA)? - (correct
answer) An end to lifetime dollar limits on what insurance companies will cover
Insurance companies can't set a dollar limit on what they spend on essential health
benefits for your care during the entire time you're enrolled in a plan.
The National Committee for Quality Assurance (NCQA) seeks to improve the quality of
healthcare by establishing and tracking more than 90 measures of care related to
providers and practitioners, which the NCQA publishes as Healthcare Effectiveness
Data and Information Set (HEDIS) and licenses for use. Who among the following is
eligible to use HEDIS results under a custom, no-cost license? - (correct answer)
Public Sector Stakeholders
NCQA supports federal, state and public-sector entities' use of HEDIS measure
specifications in their programs under a custom, no-cost license.
Which of the following is a requirement for filing a HIPAA health information privacy or
security complaint? - (correct answer) The complaint must be filed within 180 days
of knowledge of act.
This is true, although the Office for Civil Rights (OCR) may extend the 180-day period if
the filer can show "good cause."
What differences has technology made by moving from paper documentation to
electronic health records? - (correct answer) The transition from paper to
computerized documentation has improved the availability of information to care team
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller MEGAMINDS. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $11.99. You're not tied to anything after your purchase.
