C425 Healthcare Delivery Systems, Regulation, and Compliance
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Free C425 Healthcare Delivery Systems, Regulation, and Compliance Questions
Which organization develops the Healthcare Effectiveness Data and Information Set (HEDIS) to measure health plan performance?
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Centers for Medicare & Medicaid Services (CMS)
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National Committee for Quality Assurance (NCQA)
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Agency for Healthcare Research and Quality (AHRQ)
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Office of Inspector General (OIG)
Explanation
Explanation
The National Committee for Quality Assurance (NCQA), a nonprofit organization, develops the Healthcare Effectiveness Data and Information Set (HEDIS) to measure the performance of health plans and providers in areas such as preventive care, chronic disease management, and patient satisfaction. As highlighted in WGU’s C425 course, HEDIS provides standardized metrics to evaluate quality, enabling consumers and payers to compare plans and promoting accountability in healthcare delivery systems. By fostering transparency and compliance with quality standards, NCQA’s HEDIS supports improvements in care delivery and patient outcomes across the U.S. healthcare system.
Correct Answer
National Committee for Quality Assurance (NCQA)
As individuals age, the ability to remain independent in a home may change. As a result, alternate levels of care may need to be sought.
Which economic factor will influence future healthcare delivery for aging individuals?
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The supply of medicines for chronic illnesses will decrease.
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Bed availability may decrease and have a major effect on patient admittance.
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The needs of a growing population will soon outpace the production of medicines
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Costs of generic medicines will continue to decrease, and those with prescription coverage will often receive their medicine with a minimum copay
Explanation
Explanation:
The cost of generic medicines is an important economic factor influencing healthcare delivery for aging individuals. As people age, they often require medications for chronic conditions. Lower costs for generics, especially when combined with prescription coverage, make essential medicines more accessible, allowing aging individuals to manage their health effectively at home and reducing the need for more expensive institutional care.
Correct Answer:
Costs of generic medicines will continue to decrease, and those with prescription coverage will often receive their medicine with a minimum copay.
Which regulation requires healthcare organizations to implement safeguards for the security of electronic protected health information (ePHI)?
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Stark Law
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HIPAA Security Rule
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False Claims Act
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Conditions of Participation (CoP)
Explanation
Explanation
The HIPAA Security Rule, part of the Health Insurance Portability and Accountability Act (HIPAA), requires healthcare organizations to implement administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of electronic protected health information (ePHI). As a critical topic in WGU’s C425 course, the Security Rule, enforced by the Office for Civil Rights (OCR), mandates measures like access controls, encryption, and audit trails to prevent data breaches. This regulation strengthens healthcare delivery systems by ensuring patient data security, promoting compliance, and maintaining trust in the handling of sensitive health information.
Correct Answer
HIPAA Security Rule
What is the main objective of the National Practitioner Data Bank (NPDB) in the U.S. healthcare system?
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To provide health insurance coverage for physicians
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To track adverse actions against healthcare practitioners
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To regulate prescription drug pricing
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To certify electronic health record systems
Explanation
Explanation
The National Practitioner Data Bank (NPDB), established under the Health Care Quality Improvement Act of 1986, serves to track adverse actions, such as malpractice payments, licensure disciplinary actions, and privilege restrictions, against healthcare practitioners. As covered in WGU’s C425 curriculum, the NPDB, managed by the Health Resources and Services Administration (HRSA), provides a centralized database to help hospitals, licensing boards, and other entities verify practitioner credentials, enhancing patient safety and regulatory compliance. By ensuring transparency about practitioner performance, the NPDB supports the integrity of healthcare delivery systems and protects patients from unqualified or unethical providers.
Correct Answer
To track adverse actions against healthcare practitioners
What is the main goal of the Hospital Value-Based Purchasing (VBP) Program in the U.S. healthcare system?
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To regulate pharmaceutical pricing
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To incentivize hospitals to improve quality of care through payment adjustments
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To mandate electronic health record adoption
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To provide free healthcare to uninsured patients
Explanation
Explanation
The Hospital Value-Based Purchasing (VBP) Program, established under the Affordable Care Act and administered by the Centers for Medicare & Medicaid Services (CMS), incentivizes hospitals to improve the quality of care by adjusting Medicare payments based on performance metrics like patient outcomes, safety, and patient experience. As a core topic in WGU’s C425 curriculum, the VBP Program shifts healthcare delivery from volume-based to value-based care, encouraging hospitals to enhance efficiency and patient satisfaction while ensuring regulatory compliance. This initiative improves healthcare delivery systems by aligning financial incentives with high-quality, patient-centered care and reducing preventable complications.
Correct Answer
To incentivize hospitals to improve quality of care through payment adjustments
A doctor is setting up a new practice and wants to receive federal reimbursement. The doctor contacts the Center for Medicare and Medicaid Services for assistance.
Which kind of information is provided by this agency?
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Guidelines for private insurance
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Handouts for patient-related diagnosis
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Recommendations for patient confidentiality
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Parameters of the diagnostic-related groups
Explanation
Explanation:
The Centers for Medicare and Medicaid Services (CMS) provides healthcare providers with information on diagnostic-related groups (DRGs), which are used to determine reimbursement rates for inpatient hospital services. These parameters help doctors and hospitals understand how services will be billed and reimbursed under federal programs, ensuring compliance with Medicare and Medicaid payment structures and facilitating proper financial management of medical practices.
Correct Answer:
Parameters of the diagnostic-related groups
A dental department ordered new hand pieces. The Occupational Safety and Health Administration and the Centers for Disease Control mandate processing by the Sterile Processing Department to reduce exposure to patients.
Which area of concern is identified by this type of mandate?
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Infection control
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Ergonomic equipment
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Medical waste disposal
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Exposure incident response
Explanation
Explanation:
Mandates from OSHA and the CDC regarding the processing of dental instruments focus on infection control. Proper sterilization and handling of hand pieces prevent the transmission of infectious agents to patients and staff. By adhering to these regulations, healthcare facilities maintain safe environments, reduce the risk of healthcare-associated infections, and comply with national safety and public health standards.
Correct Answer:
Infection control
Which organization is primarily responsible for enforcing healthcare fraud and abuse laws in the U.S.?
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Food and Drug Administration (FDA)
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Office of Inspector General (OIG)
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Centers for Disease Control and Prevention (CDC)
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National Institutes of Health (NIH)
Explanation
Explanation
The Office of Inspector General (OIG) within the Department of Health and Human Services is primarily responsible for enforcing healthcare fraud and abuse laws in the U.S. The OIG investigates fraudulent activities, such as false billing or kickbacks, in federal healthcare programs like Medicare and Medicaid, ensuring compliance with laws like the False Claims Act and Anti-Kickback Statute. As highlighted in WGU’s C425 course, the OIG’s oversight protects the integrity of healthcare delivery systems by deterring unethical practices, recovering misspent funds, and imposing penalties on violators. This enforcement promotes accountability among providers and supports equitable access to care by safeguarding public resources, aligning with the broader regulatory framework of the U.S. healthcare system.
Correct Answer
Office of Inspector General (OIG)
Which two benefits can be expected given the new trend of health care moving to a more preventative model?
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Longer life spans
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Shorter wait times
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Increased medical costs
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Decreased medical costs
Explanation
Explanation:
A preventative healthcare model focuses on early detection, health maintenance, and disease prevention. This approach can lead to longer life spans because conditions are treated or managed before becoming severe. Additionally, by preventing complications and reducing hospitalizations, preventative care helps decrease overall medical costs for both patients and the healthcare system. Early interventions are generally less expensive than treating advanced diseases.
Correct Answer:
Longer life spans
Decreased medical costs
In 2010, President Obama signed into law the Patient Protection and Affordable Care Act.
What was the initial intended impact of this Act?
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To ensure that elderly will have access to health care
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To ensure that caregivers will have access to health care
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To ensure that uninsured individuals have access to health care
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To ensure that military personnel will have access to health care
Explanation
Explanation:
The Patient Protection and Affordable Care Act (ACA) was designed to expand health care coverage to millions of Americans who were previously uninsured. Its primary goal was to increase access to affordable health insurance, reduce the number of uninsured individuals, and improve overall public health outcomes. While it affected many groups indirectly, the initial focus was on providing health care access to those without any coverage.
Correct Answer:
To ensure that uninsured individuals have access to health care
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