ABPS Healthcare Systems & Administration 2 — Questions and Answers
Question 1: Which federal agency oversees the Medicare and Medicaid programs in the United States?
- The Department of Health and Human Services (DHHS)
- Centers for Medicare & Medicaid Services (CMS) (Correct answer)
- The Joint Commission (TJC)
- Agency for Healthcare Research and Quality (AHRQ)
Correct answer: Centers for Medicare & Medicaid Services (CMS)
CMS, a federal agency within DHHS, administers Medicare, Medicaid, CHIP, and other health-related programs.
Question 2: A hospital's 'case mix index' (CMI) is primarily used to measure which of the following?
- The average length of patient stays
- The complexity and resource intensity of patient cases (Correct answer)
- The ratio of inpatient to outpatient encounters
- The percentage of Medicare versus Medicaid patients
Correct answer: The complexity and resource intensity of patient cases
CMI reflects the average clinical complexity and resource use of inpatient cases, influencing hospital reimbursement and resource planning.
Question 3: Under EMTALA, what is a hospital's obligation when a patient presents to the emergency department?
- Provide care only to patients with insurance
- Screen and stabilize any patient regardless of ability to pay (Correct answer)
- Transfer all uninsured patients to county hospitals
- Obtain pre-authorization before rendering any treatment
Correct answer: Screen and stabilize any patient regardless of ability to pay
EMTALA requires hospitals to provide a medical screening exam and necessary stabilizing treatment to all emergency patients regardless of insurance or financial status.
Question 4: Which payment model reimburses a fixed amount per patient per month regardless of services used?
- Fee-for-service
- Pay-for-performance
- Capitation (Correct answer)
- Per diem
Correct answer: Capitation
Capitation is a payment arrangement where a provider receives a set amount per enrolled patient per month, incentivizing cost-efficient preventive care.
Question 5: What does the term 'credentialing' refer to in a hospital setting?
- Verifying a physician's education, training, licensure, and competence before granting privileges (Correct answer)
- Issuing billing codes for clinical procedures
- Establishing quality benchmarks for nursing staff
- Registering the hospital with state health departments
Correct answer: Verifying a physician's education, training, licensure, and competence before granting privileges
Credentialing is the process of verifying a provider's qualifications and granting clinical privileges to practice within a healthcare institution.
Question 6: Which accreditation body sets standards for hospitals in the United States and conducts on-site surveys?
- National Committee for Quality Assurance (NCQA)
- The Joint Commission (TJC) (Correct answer)
- Utilization Review Accreditation Commission (URAC)
- American Medical Association (AMA)
Correct answer: The Joint Commission (TJC)
The Joint Commission accredits and certifies healthcare organizations, and its accreditation is often required for Medicare/Medicaid participation.
Question 7: A Diagnosis-Related Group (DRG) is best described as:
- A quality metric used to rank hospitals by patient outcomes
- A classification system used to determine Medicare inpatient reimbursement (Correct answer)
- A method of tracking chronic disease prevalence in populations
- A billing code for outpatient physician services
Correct answer: A classification system used to determine Medicare inpatient reimbursement
DRGs classify hospital inpatient cases into groups expected to have similar resource use, and Medicare pays a fixed rate per DRG rather than for individual services.
ABPS Healthcare Systems & Administration 2
Which federal agency oversees the Medicare and Medicaid programs in the United States?