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Intro 2 PT

Mid term review Module 3 and 4

QuestionAnswer
what is critical thinking? a mutifaceted, analytical thought process by accumulating data, synthesizing that info, and applying sound judgment. aka, systematic approach.
In critical thinking, what was be confronted? personal biases
what is metacognition he active process of monitoring and considering one's thoughts and values and what influences those thoughts and values while actively engaged in the thinking process
Why EBP now? APTA 2020 vision, DPT credential, "Consumer Driven" cost conciousness on health care delivery, and accountability demands on professionals
what is Evidence Based Practice (EBP)? (in simple terms) •Acquisition of reliable information that supports or demonstrates that something is true
what is the APTA's def of EBP? ◦the integration of the best available research, clinical expertise, and patient values and circumstances related to patient/client management, practice management, and health policy decision making
what are the 3 primary types of Evidence in EBP? Empirical Evidence, Analogical Evidence (comparison between 2 systems and hypothesizing relational similarities), and Anecdotal Evidence (individual's experience)
What are some of the limitations of EBD? lack of research skills and information resources, difficulty in applying to individual patient conditions and care, inconsistent culture in PT regarding EBP,
what is Ethics in PT? outcomes? Normative inquiry into the moral decisions and principles, ideals and virtues, and policies and laws concerning PT. Outcome: Consistent desirable conduct, beliefs and character of PTs
What are our 7 core values? accronym: IS A PACE I- integrity, S-social responsibility, A- altruism, P- professional duty, A- accountability, C- compassion/caring, E- excellence
Identify which core value is associated with each principle: 1: Physical therapists shall respect the inherent dignity and rights of all individuals. •core values: compassion, integrity
Identify which core value is associated with each principle: 2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients/clients •Core Values: Altruism, Compassion, Professional Duty
Identify which core value is associated with each principle: 3: Physical therapists shall be accountable for making sound professional judgements •Core values: excellence, integrity
Identify which core value is assoc. w/each principle: 4: PTs shall demonstrate integrity in their relationships w/ patients/clients, families, colleagues, students, research participants, other health care providers, employers, payers, + the public. core value: integrity
Identify which core value is associated with each principle: 5: PTs shall fulfill their legal + professional obligations (i.e. practice w/in our guidelines comply w/laws, supervise PTAs properly, encourage coworkers to seek counsel if needed, etc.) core value: accountability, professional duty
Identify which core value is associated with each principle: 6: Physical therapists shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors. Core value: excellence
ID which core value is associated w/ each principle: 7: ie, promote organizational behaviors +business practices that benefit patients+society (support autonomy in practice environments, seek remuneration, not accept gifts, no 2nd job if creates conflict) core value: integrity, accountability
Identify which core value is associated with each principle: 8:PTs shall participate in efforts to meet the health needs of people locally, nationally or globally core value: social responsiblity
Why and when was the Consumer Bill of Rights and Responsibilities created? bill created in 1997-98 by Prez Clinton that outlined guidelines for continued quality, value and consumer protection, and as way to unify standards for all industry standards
What is the Consumer Bill of Rights and Responsibilities? (8 areas covered) bill strengthens consumer confidence by ensuring information disclosure, choice of providers/plans, access 2 emergency services, participation in HC decisions, nondiscrimination, confidentiality, complaint appeal process, + outline consumer responsibility
Health Insurance is "shifting exposure of financial risk from _____ to ______? from the consumer/patient to the insurance insitution/organization
Name the 3 entities that finance Health Care: Individual, Employer, Government
Identify all 3 players of the "3rd party system" consumer, provider, payer
What is the difference btwn Medicaid and Medicare? Medicare is soley Gov funded and is for those who are over 65, End State Renal Disease, or disabled. Medicaid is funded jointly- state AND gov. based of household income/poverty level. regualted at state level.
What is State Children Health Insurance Program? SCHIP- joint funded by state AND gov. also regulated at STATE level. designed to help families that are above poverty level but cant afford insurance
There are 4 parts to Medicare, explain part A: A: "entitlment program"- covers In-Patient services.
There are 4 parts to Medicare, explain part B: B: "voluntary" choice 2 pay for out of pocket- will cover outpatient services
There are 4 parts to Medicare, explain part C: C: -“voluntary” option to pay out of pocket in lieu of B, and option to buy MCO (for outpatient services, but managed by HC company) less expensive than B!
There are 4 parts to Medicare, explain part D: D- “entitlement”- prescription drug plan
define: Insured entity covered by health insurance policy, subscriber or dependent
define: Subscriber the person, usually the employee, who represents the family unit in relation to the policy plan.
define: insurer health insurance company, or entitity that is assuming risk
define: covered service those goods/products or services that are reimbursed by insurance company, that is provided for in the "policy"
define: allowable The total amount that the insurance company recognizes as full payment to the provider. this includes both the insurer and insured payments.
define: deductible the amt the insured incurs b4 a health insurance company will pay the remaining costs. i.e. annual deductible ($500) must be paid out of pocket b4 insurance "kicks in"
define: coninsurance the cost sharing obligation of the member, after the deductible has been met. this is a PERCENTAGE OF THE ALLOWABLE. paid to PROVIDER
define: copay this is a pre-determined fee. paid to PROVIDER.
define: fee amount the provider charges. (many times gets ignored!)
define: entitlement: a right or proviledge based on criteria met or qualified for.
define: premium the cost of health insurance, typically paid monthly. goes to health insurance company.
define: DME Durable Medical Equipment- Equip. that a practioner prescribers for patient's use.
define: Open Enrollment annual period designated when an employee has an opportunity to switch to a new health insurance plan
define: claim vehicle used for provider to bill insurance company for services provided. manual or electronic.
define: EOB explanation of benefits. what the insurance company will send to provider and patient to inform both what was amt allowed and amt paid.
define: Carrier another word for "insurer" or insurance company
define: cost the expenses associated with the delivery of a service. NOT THE SAME AS FEE! this may include PT's salary, cost to use equip, rent of facility, etc.
What was the significance of Balanced Budget Act of 1997 (BBA) n attempt to balance the federal budget deficit. (Clinton) What they wanted to do was take a look at entitlement programs within federal programs and cut them. There were massive layoffs in PT. moving towards a PPS.
What was the significance of Medicare Modernization Act (2003)? largest overhaul of Medicare, essentially gave more option to medicare recipients thru MCO and prescription drug coverage proposed, C and D.(medicare C and D rolled out in 2006)
What was the significance of Medicare Modernization Act (2010) Medicare B premiums adjusted based on subscriber income
What were the 2 reimbursement methods used in "retrospective reimbursement?" FFS: reimbursement after the fact, seen in outpatient evnviro. Indemnity Insurance: a type of insurance that everything is convered, under the plan, as long as its "Usual and Customary"
In "prospective payments," explain what a DRG and RBRVS is? DRG- diagnostic related group. a flat amt the insurance co will pay to hospital based off diagnostic. RBRVS: is a resource based relative value scale- listing of fees according to procedures taking into account, technical, cost to practice, +malpractice
When were Pospective Payments developed? with the Balance Budget Act of 1997
What is an MCO? Managed Care Organization. created by the HC system to control financing, typically thru an administrator. 3 components define it: discounted fee schedule, provider network (panel), and restricted access to HC
what are the 3 primary types of MCOs? Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Point of Service (POS) plan.
What's the concept of managed care? insurance plans that contract w/providers +med facilities 2 provide care 4 mbrs @ reduced costs. These providers make up the plan's network. How much of ur care the plan will pay4 depends on the network's rules.Restrictive plans cost less+flex cost more.
Which is most traditional? HMO, PPO, or POS? explain how the network worked? HMO- no out of network benefits. very affordable, but most restrictive.
What's the difference btwn a HMO, PPO and POS as the provider? HMO- employed by HMO (staff model) or contracted out (IPA model). PPO- "guaranteed" # of patient's bc network is restricted, in exchange you accept discounted fee when PPO pays you. in POS- in a network, similar to PPO.
What's the difference btwn a HMO, PPO and POS as the patient? HMO: no Out of Network, most affordable. most restrictive. PPO: "preferred network" but u can $ to go OON,(70/30) not as restricted. POS- both out and in network providers, least restrictive. high out of pocket expense and anual deductible.
Consumer Driven Health Plan: describe a MSA (aka HSA). Medical and Health Savings Account- Individual owns. rollover account that you contribute to pretax, you can use for routine medical care. you must have a HIGH DEDUCTIBLE HEALTH PLAN (HDHD) with this! HDHD is syn with catastrophic health insurance.
Consumer Driven Health Plan: describe a FSA Flexible Spending Account: does not rollover, use it or lose it (1 yr). Employer owns, held in employee name benefit. earnings to this tax exempt account. Offered with more tradtional health insurance plans. covers dependents too.
Consumer Driven Health Plan: describe a HRA Health Reimbursement Account: Employer owns. employer determines if rollover or not.  Employer owns the account (and pays into account) to reimburse individual for paid medical expenses
Created by: tpostrel