Master Study Guide III
Encounter
1. Pre-Encounter refers to ________________________________________.
2. Encounter refers to ____________________________________________
3. The responsibilities of the Access Representative are to:
a. _______________ information
b. appropriately identify the ________________
c. insure ___________________ for services
d. communicate information concerning patient’s _______________
e. obtain consents from ________________and authorizations from ________________
f. collect co-pays and ________________
g. direct the patient to the ________________ of ______________
h. make the patient feel comfortable and _____________________.
4. The Medicare form relating to medical necessity is known as the _________________
________________ _________________.
5. First impressions are imprinted in the patient’s mind during the _________________ because
they can observe the staff’s _________________ and attitudes.
6. The MOST IMPORTANT task undertaken by patient access is proper ______________
______________________.
7. Proper patient identification includes obtaining the patient’s _____________ name, _____________, and
additional identifying information.
8. A massive list containing the names of all patients who have ever received service at a medical
facility is known as the ___________________ _________________ ___________________.
9. Patient identification information is matched against the ________________ _______________
______________ for matches.
10. The Joint Commission’s number ONE goal is improving patient ___________________ which
improves patient ___________________.
11. All healthcare workers must use a minimum of ___________ identifiers (name, date of birth, etc.)
when providing care treatment, and services.
12. In addition to accurately identifying the patient, patient access staff should follow the
facility directed guidelines to secure the patient’s _______________ and ______________
information.
13. Doing so helps prevent _______ __________ and ______________ _______________.
14. The _______________ _________________ is a good source of information to determine if the patient has
special needs.
15. According to Title III of the Americans with Disabilities Act, __________________ ____________________
must be identified and accommodated/addressed for those with Limited English Proficiency.
16. Reasonable steps must be taken to communicate effectively with patients, family
members, and ______________. This also included those who are _____________ of ____________.
17. The Joint Commission requires that hospitals provide a ______________ reduction program
because if a patient falls on an unmarked wet floor, UMHC will be _____________ for the
medical bills.
18. Hospitals must also provide waiting room chairs, special beds, and large wheelchairs to
preserve the dignity and safety of _____________ patients.
19. Also known as ‘bed control’ or ‘bed placement’, hospitals must provide the most
_____________ location and level of service necessary for ______________ clinical care. CHAA
refers to this as _____________ _________________ and it involves the collection and
documentation of the information necessary to determine if the requirements are met.
20. An important factor to consider in patient placement is _____________ ______________.
a. In acute care hospitals, infected patients should be placed in _____________
rooms when available.
b. When not available, patients with the same MRSA should be placed in the
_____________ room or patient care area.
21. Staph infections, including MRSA occur most frequently among persons in hospitals and
healthcare facilities with ______________ immune systems.
22. The Center for Disease Control and Prevention (CDC) identified these standard
precautions as crucial to preventing the spread of disease:
a. ___________________ __________________
b. __________________ _______________ equipment
c. ______________________ etiquette
23. If hands are not soiled, the preferred method of decontamination is an _____________
based hand rub. If hands are visibly soiled, use only after removing visible materials
with ________ and __________.
24. Alcohol-based rubs kill germs more _________________ and _____________,
a. are less _______________ to the skin
b. require less ___________
c. and are more _____________ than soap and water.
25. Medical attention given for a sudden onset of an illness that demands urgent (quick)
attention of limited duration (time) when the patient’s health and wellness would
deteriorate without treatment is known as ______________ ___________.
26. Observation care is limited to:
a. the use of a __________ and periodic ___________ by hospital staff
b. Services should be reasonable and necessary to ______________ the need for a
possible hospital admission.
c. Care USUALLY doesn’t exceed ___________ hours.
27. _______________ ___________ is treatment received at a hospital, clinic, or dispensary but the
patient is not hospitalized.
28. A scheduled or non-scheduled service such as radiology, laboratory, or other services
performed in a hospital or clinic where patient leaves the facility once services are
completed is known as _________________ _______________________.
29. In Emergency Services, patients are examined on an _________________ _______________ basis
for _____________________ treatment in the emergency facilities at a hospital.
a. Depending on diagnosis, patient could be admitted as an _______________,
____________, or transferred to another facility.
30. ____________________ ___________________/Same Day Surgery is where patient receives surgical
treatment and is discharged within ______ to _____ hours of procedure.
31. ___________________ Services are known as physical/occupational therapy, cardiac or
pulmonary rehab that occurs over time based on doctor’s order.
32. Long Term Care is generally provided to the __________________ ill, _____________, or those in
a nursing home.
a. Services include 24 hour _______________ care,
b. Occupational/Physical/Speech __________ as well as assistance with daily
living.
c. Medicare beneficiaries are eligible for _________ days and Medicaid is available
for those who have ___________________ their own resources.
33. _____________________ ______________ is short term care provided to people caring for
elders/mentally/physically dependant family members.
a. It gives the care givers ________ ____________ from taking care of their loved ones.
b. It is not _______________ through Medicare or Medicaid.
34. ___________________ is a non-profit organization dedicated to families and patients facing
___________ illness or ____________.
a. It allows patients to share their last days together in their own ___________ or
hospice designated facility.
b. It is ____________ under Medicare.
35. Demographic information has both a ________________ and _______________ purpose and must
be __________________and complete.
36. Demographic information is verified by obtaining positive __________________ of the
patient in combination with a
a. ____________ ____________ conducted using
b. ____________ ___________ questions.
37. In patient access, the patient or _______________ ______________________ is required to sign the
consent form which should be:
a. _________________ prior to obtaining signature and the patient should be given
b. __________ to __________ the document and ask __________.
c. Most facilities include on this form a release of information for ______________
purposes.
38. The patient or patient representative must ___________ and _________ the form and may be
required to list their:
a. _______________ to the patient.
b. Patient Access Staff must also sign the form as a _______________.
39. If a patient’s condition prevents them from signing and no patient representative is
available, the patient access rep should ______________ that on the form and ________ as a
witness. Of course, they must also follow up with the patient or patient rep to obtain
consent when available.
40. When patient refuses to sign consent form in a scheduled, elective, or walk in clinic,
___________________ or ________________ involvement may be required to address patient
concerns.
41. Some patients may be unable to sign because they are _______________.
a. If so, there is usually a guardian or durable _______________ of ______________
assigned.
b. Patient access should obtain a ____________ of the power of attorney form to be
included in the medical record proving the individual has the right to sign
legal documents on behalf of the patient.
42. Consent regarding ________________ is complicated. Consent must be obtained from a
parent or legal guardian prior to providing _________________ services for a minor.
43. If a minor presents for services without a guardian, patient access staff can contact via
_________________ for verbal consent, if they document on consent form. Some facilities
may require a _______________ staff member to verify verbal consent and document as
well.
44. Minors presenting for scheduled/elective procedures without a guardian should
require _______________ and ________________ __________________ to confirm that the necessary
consents have been obtained.
45. Some states DO NOT require consent for minor treatment to obtain services
for_____________ related services, contraceptive/STD related services, mental Health
Services, and substance abuse treatment.
46. ________________ _______________ do not need consent from a guardian.
47. ______________________ is not available in every state in the US. Where available, minors
obtain legal adulthood before the normally required age. Rights associated with this
might include the ability to ___________ legally binding contracts, own property, and keep
one’s earnings. Laws vary from state to state.
48. In most cases, there are 3 circumstances in which a minor becomes emancipated: 1)
enlisting in the ______________, getting _____________, or obtaining a court order from a
__________.
49. The HIPPA ___________________ of _____________ _____________ (NOPP) explains how protected
health information (PHI) is used and disclosed in healthcare.
a. All providers are required to make the NOPP available to _____________ and
obtain a ________________ acknowledgement from patient that the information
was offered.
50. The signed NPP remains in effect for all subsequent (later) visits unless the Notice
_____________.
a. When there is a _______________ revision of the Notice, providers must
distribute the new Notice to patients and obtain a new _______________.
51. Patients have the right to file a complaint or grievance (when) _______________ during the
healthcare encounter.
52. Patient’s rights and responsibilities must be ____________ throughout the facility and
many states require a __________ version to be available upon admission.
53. The Patient Self Determination Act (PSDA) of 1990 affords patients the right to
_________ or ____________ treatment.
a. State laws vary on which legal documents to recognize regarding Advanced
Directives, Living Wills , and Power of Attorney for Healthcare, but no state
may ____________ (prevent) the patient’s right to participate in ____________
_______________.
54. An __________________ ____________________ or ______________ _____________ is written instructions
regarding an adult patient’s wishes when they cannot make healthcare decisions for
themselves.
55. A Durable _______________ of _______________ is the portion of the advance directive where
an adult person appoints a _____________ or ____________ (actual person) to make decisions
if the patient becomes incapacitated and unable to make their own decisions.
56. The PSDA requires that patients be _____________ about advance directives and
______________ if they have completed one.
a. If so, the provider is responsible to _____________ it in the patient’s medical file
in an easily _____________ place to all healthcare providers.
57. An Advanced Directive is activated when a patient becomes ________________. A person
can _______________ (cancel) it at any time by destroying all copies.
58. ‘An Important Message from Medicare’ is a form explaining beneficiary rights and
instructions on how to file an ________________(formal complaint) in the event that the
patient disagrees with the discharge plan or has a complaint.
a. The form should be _____________ to the patient _________ to admission and
signed by the patient stating they have received the information.
b. The Provider must re-present the form to the patient ___________ to discharge
giving the patient the opportunity to initiate the appeal before the discharge
occurs.
59. First Party - ______________
a. Second Party - ____________
b. Third Party - __________
60. Patient Insurance and Payment information must be correctly obtained from the
patient to insure proper claim submission to the ______________ _______________
_______________.
61. Medicare is the nation’s largest health insurance program covering more than ________
million Americans annually.
62. Medicare Beneficiaries are those who are at least _________ years old, under the
required age, but qualify due to ____________, and those with _________________.
63. Traditional Medicare (Part A/B) usually only covers prescription drugs for
_______________ stays.
a. It does not cover prescription drugs for __________________ services.
b. Everyone with Medicare can obtain Medicare Part _______ which is
prescription drug coverage.
64. Generally patients are eligible for Medicare if the patient or their ______________ worked
for at least ________ years in Medicare covered employment,
a. is ______ years or older
b. and is a ________________ or permanent resident of the US.
65. Medicare Beneficiaries do not pay a premium IF they receive benefits from:
a. _____________ ________________
b. the ___________ Retirement Board
c. if they are eligible for previous requirements but haven’t __________ for them
yet
d. if their spouse had Medicare covered ______________________ employment.
66. They will also not pay a premium for Part A if they are ________________ age 65 and have
received Social Security or Railroad Retirement Board disability benefits for _________
months or has ______________ and meets certain requirements.
67. The ______________ __________ _____________ _______________ determines who pays first for
Medicare Patients.
68. The private insurance industry uses the term __________________ _____ ______________ to
determine the primary and secondary payers.
69. The Medicare Secondary Payer Questionnaire asks for information to determine if
the injury is ____________ related
a. if the patient has ___________ insurance
b. is __________ years or older
c. if they have coverage through a __________ ____________ _________ _________ (LGHP)
d. if the patient is covered under their _____________ insurance
e. if they qualify due to __________________ or _______________
f. if the qualify under the Federal ____________ Lung program,
g. _________________ Administration
h. Government __________________ Grant.
70. If the patient is 65 years or older and is covered by a group health plan with 20 OR
MORE employees due to their own or their spouse’s employment, _______________ pays
first and _________________ pays second.
71. If the patient is 65 years or older and is covered by a group health plan with LESS THAN
20 employees due to their own or their spouse’s employment, _______________ pays first
and _________________ pays second.
72. If the patient has an employer group health plan after they retire and are age 65 or
older, ______________ pays first, ________________ pays second.
73. If the patient is disabled and covered by a large group health plan from work or from a
family member’s employer who has 100 or more employees, __________________ pays first,
and __________________ pays second.
74. If the patient is disabled and covered by a large group health plan from work or from a
family member’s employer who has less than 100 employees, __________________ pays first,
and __________________ pays second.
75. Medicare Part A entitled beneficiaries who have terminal illnesses and a life expectancy
of less than 6 months can elect ________________ benefits in lieu (instead) of standard
Medicare coverage as long as the provider is a _______________ certified hospice provider.
76. Medicare Advantage Plans are health plan options like ___________ or _________ run by
___________ companies who are approved by Medicare.
77. Other names for Medicare Advantage Plans are _________________ and ___________ plans.
78. Medicare Advantage Plans are NOT _____________________ _________________. MA Plans
replace coverage and are not additional. (supplemental = additional)
79. There are __________ (number) different kinds of Medicare Advantage Plans. Most of
them, like HMOs, have a _____________ of doctors and hospitals the patient must choose
from to be covered.
a. Others who allow the patient to go to any doctor who agrees to accept plan’s
terms of payment are known as _______________ ______ _____ _____________ Plans.
80. Another MA Plan that serves certain Medicare beneficiaries who are chronically ill, live
in institutions like nursing homes, or who have other special needs are known as
______________ _______________ _____________ Plans.
81. Medicaid is available to certain ________ income individuals or families. State rules vary
about requiring the patient to pay a ____ _________ for some services.
82. Medicaid is a ______________ administered program where each state sets its own
guidelines regarding eligibility and services.
83. Many groups of people are covered by Medicaid but within these groups certain
requirements must be made. These requirements may include ____________,
a. medical condition (________________, _______________, __________, or aged)
b. income and resources (____________ ____________, ___________ ____________, etc)
c. whether patient is a ____________ or a lawfully admitted __________________.
d. The rules for counting income and resources vary from state to _____________
and group to ___________.
84. Medicaid does not provide medical assistance for all ______________ ______________ residents.
a. Even the most unfortunate persons must meet certain _______________
requirements.
b. __________ _____________ is only one test for Medicaid eligibility;
c. ___________ and ________________ are also tested against eligibility thresholds.
85. _____________ and _______________ are examples of assets.
86. Medicaid coverage may start retroactive to any or all of the __________ months prior to
application. When coverage stops, it usually stops at the _________ of the month in which
a person’s circumstances change.
87. Managed Care is any system that aims at delivering healthcare and controlling _________.
a. They TYPICALLY use a _______________ ____________ __________________ who acts as a
gatekeeper through which a patient has to go through to obtain special
health services.
88. Which Managed Care plan uses a PCP?
89. Which uses a network of doctors?
90. Managed Care Organizations frequently contract with health care providers like
________ and _________ who agree to deliver services according to specific stipulations.
91. These stipulations usually revolve around the ____________ and medical __________ of the
services.
ANSWERS
1. Before the patient arrives at hospital
2. The time while the patient is at the hospital
3. Answers
a. Gather
b. Patient
c. Reimbursement
d. Rights
e. Patients, Payers
f. Deductibles
g. Point of service
h. Important
4. Advanced Beneficiary Notice
5. Encounter, behavior
6. Patient identification
7. Legal, date of birth
8. Master Patient Index
9. Master Patient Index
10. Identification, safety
11. Two
12. Demographic and financial
13. ID Theft, Insurance Fraud
14. Physician Orders
15. Language Barriers
16. Visitors, hard of hearing
17. Fall, liable (responsible)
18. Obese
19. Appropriate, optimum, patient placement
20. Infection control
a. Private
b. Same
21. Weakened
22. Answers
a. Hand hygiene
b. Personal protective
c. Cough/respiratory
23. Alcohol, soap and water
24. Effectively and quickly
a. Damaging
b. Time
c. Accessible
25. Acute Care
26. Answer
a. Bed, monitoring
b. Evaluate
c. 24-48 hours
27. Outpatient care
28. Ancillary services
29. Unscheduled emergent, immediate
a. Observation, inpatient
30. Ambulatory Services, 4-6
31. Recurring
32. Chronically, disabled
a. Nursing
b. Therapy
c. 100, exhausted
33. Respite Care
a. Time off
b. Reimbursed
34. Hospice, chronic, death
a. Home
b. Reimbursed
35. Clinical, financial, accurate
36. Identification
a. Verbal interview
b. Open-ended
37. Patient representative
a. Explained
b. Time to review, questions
c. Financial
38. Sign, date
a. Relationship
b. Witness
39. Document, sign
40. Supervisory or clinical
41. Incapacitated
a. Power of attorney
b. Copy
42. Minors, non-emergent
43. Phone, second
44. Supervisory or clinical involvement
45. Pregnancy
46. Emancipated minors
47. Emancipation, sign
48. Military, married, judge
49. Notice of Privacy Practices
a. Patients, signed
50. Changes
a. Material, signature
51. Anytime
52. Posted, written
53. Receive or refuse
a. Prohibit, decision making
54. Advanced Directive or Living Will
55. Power of Attorney, proxy, advocate
56. Educated,asked
a. Place, viewable
57. Incapacitated, revoke
58. Appeal
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
a. Explained, prior
b. Prior
Patient
a. Provider
b. Payer (Insurance Company)
Third Party Payer
40
65, disability, ESRD
Inpatient
a. Outpatient
b. D
Spouse, 10
a. 65
b. Citizen
Social Security
a. Railroad
b. Filed
c. Government
Over, 24, ESRD
Medicare Secondary Payer Questionnaire
Coordination of Benefits
Work
a. Group
b. 65
c. Large Group Health Plan
d. Spouse’s
e. Disability or ESRD
f. Black
g. Veterans
h. Research
Large Group Health Plan, Medicare
Medicare, Small Group Health Plan
Medicare, Retiree Insurance
LGHP, Medicare
Medicare, SGHP
Hospice
PPO or HMO, private
Part C, MA
Supplemental insurance
5, network
a. Private fee for service
Medicare Special Needs
Low, co-payment
State
Age
a. Pregnant, disabled, blind
b. Bank accounts, real estate
c. US Citizen, immigrant
d. State, group
Low income
85.
86.
87.
88.
89.
90.
91.
a. Eligibility
b. Low income
c. Assets and resources
Houses, cars, jewelry, land, etc
Three, end
Costs
a. Primary care physician
HMO
PPO
HMO and PPO
Payment, necessity