Question

Review Questions 1. Compare and contrast two of CMS's value-based purchasing programs. 2. Caitlin's physician suspects that he hae chaleuretitis and has ordered a gallbladder ultrasound to be Performed. The staff at the physician's office contacts Caitlin's third-party payer to determine benefits and coverage for this procedure prior to scheduling the cholecystectomy. What is this process called? a. Utilization management b. Explanation of benefits c. Payment adjudication d. Preauthorization 3. Discuss the relationship between payment for healthcare services and quality of patient care, and how this has evolved into value-based purchasing. 4. If a patient comes into the emergency department with left-sided hemiparesis that started within the last three hours, which admission criterion would be used to justify admitting this patient as an inpatient? a. Intensity of service b. Indicator c. Severity of illness d. Standard of care 5. What organization was formed in the late 1980s to address the lack of uniform standards for utilization review services by promoting quality and accountability of healthcare organizations through accredita- tion, education, and measurement programs? a. The Joint Commission b. CMS c. NCQA d. URAC

Answer 1

1)Value based purchasing programs are the incentives which CMS provides to hospitals for delivering quality care .value based purchasing programs are broadly classified in to 4 domanis like qualify care in relation to safety,clinical care,cost reduction and cost effective and patient and care giver centred experience .

Program 1: Catheter Associated Urinary tract infection this is part of hospital acquired conditions in the domain of safety .This incentive is provided to hospitals in providing quality care to patients with Foley's catheter and prevention CAUTI .They use NHS CDC surveillance system to calculate the rates in Medicare claim discharges

Program 2 :Nurses communication is part of patient and care giver centred experience of care.The CMS provides incentive. For hospitals with excellent nurse patient communication.They use various tools to assess the effectiveness of communication like ISBAR ,AIDET technique of communication.

2 Answer a: Utilization management it is the process of reviewing the Utilization of available insurance which asks the insurance companies to check the appropriateness of a particular procedure,and which help them to manage the cost pertaing to the procedure . pre-authorization is a subset of utilization management only once they review will they give pre-authorization.explanation of benefits is a procedure in which a third party company explains the benefits and mediclaims available for the customer in particular disease or procedure.payment adjudication is a procedure where the insurance companies settle the financial burden of the patient after the procedure in the form of full reimbursement or half reimbursement.

3.Earlier hospitals were payed for the quantity of care provided but recently with quality patient care as the priority CMS has started with giving incentive to hospitals providing quality care which is called value based purchasing .CMS awards reimbursed a hospitals based on the quality care provided .the hospitals are measured against a set benchmark .CMS encourges hospitals to provide quality care, appropriate clinical care and make the patient and relatives comfortable .By the evolution of value based purchasing hospitals have no option but to give quality care to receive funds and reimbursement.This has led to improved quality care ,hospitals taking part in quality initiatives.

4) Answer c severity of illness because a patient with hemiparesis since last 4 hrs could be a stroke related to Intracranial bleed or cerebrovascular accident .which needs hospital admission intensity of service is when an admission is needed for any high risk procedure like Primary angioplasty in MI indicator and standard of care are not the criterias for admission.