Deck 7: Unraveling the Mysteries of Managed Care

Question 1

With many MCOs,the enrollee typically pays a small fee up front called a ____________________when visiting his or her PCP.

Answer 1

copayment

Question 2

A multispecialty practice in which healthcare services are provided within the building complex owned by the health maintenance organization (HMO)is referred to as a/an:

A) IPA.
B) staff model.
C) network model.
D) direct contact model.

Answer 2

staff model.

Question 3

A specific provider who oversees the total healthcare treatment of an individual enrolled in certain managed care plans is generally referred to as a:

A) participating provider.
B) primary care physician.
C) principal care provider.
D) treatment administrator.

Answer 3

primary care physician.

Question 4

A healthcare provider trained in a particular medical specialty is a:

A) specialist.
B) consultant.
C) counselor.
D) participating provider.

Question 5

An advantage of managed care organizations (MCOs)is that their aim is to keep their enrollees healthy,which is commonly referred to as:

A) health options.
B) preventive care.
C) all-inclusive care.
D) defensive treatment.

Question 6

Individuals who are members of a managed care plan are commonly referred to as:

A) patients.
B) employees.
C) enrollees.
D) subscribers.

Question 7

A common process used by many healthcare payers to monitor and control healthcare costs by prior evaluation and necessity of most hospitalizations and certain medical services.

A) Appeal
B) Grievance
C) Equalization
D) Preauthorization

Question 8

In which type of managed care organization may services be furnished at discounted rates if the members receive their healthcare from member providers but pay a higher out-of-pocket cost when going outside the organization?

A) HMO
B) PPO
C) PCP
D) IPA

Question 9

An independent nonprofit organization that measures,assesses,and reports on the quality of care and service in MCOs.

A) AMA
B) NUCC
C) HIPAA
D) NCQA

Question 10

Which federal act,passed in 1996,is intended to improve the efficiency of healthcare delivery,reduce administrative cost,and protect patient privacy?

A) HCFA
B) HIPAA
C) EMTLA
D) COBRA

Question 11

A specific provider who oversees the entire care and treatment of a patient in an HMO is called a ___________.

Question 12

Managed care is a healthcare system where insurance companies attempt to control _____ healthcare.

A) cost of
B) quality of
C) access to
D) all of the above

Question 13

A relatively small out-of-pocket dollar amount that a member of a managed care plan typically pays up front is:

A) a copayment.
B) a deductible.
C) a premium.
D) compensation.

Question 14

A group of healthcare providers working under one umbrella to provide medical services at a discount to the individuals who participate in the plan is referred to as a/an:

A) HMO.
B) FFS.
C) AMA.
D) PPO.

Question 15

An independent,not-for-profit organization that evaluates and accredits healthcare organizations and is considered the predominant standards-setting and accrediting body in healthcare in the United States.

A) AMA
B) NUCC
C) The Joint Commission
D) NCQA

Question 16

A system designed to determine the medical necessity and appropriateness of a requested medical service or procedure is a/an:

A) appeal.
B) petition.
C) utilization review.
D) needs evaluation.

Question 17

A request by a healthcare provider for his or her patient to be evaluated or treated by a specialist is a:

A) referral.
B) consultation.
C) confirmation.
D) preauthorization.

Question 18

A/an __________,similar to the group model HMO,allows multiple provider arrangements,but services are provided at multiple sites by multiple groups so that a wider geographic area is served.

A) IPA
B) network model
C) point-of-service
D) direct contact model

Question 19

The formal term for a written complaint submitted by an individual covered by a special plan or policy is called a:

A) letter.
B) grievance.
C) complaint.
D) dispatch.

Question 20

A complex healthcare system in which hospitals and healthcare professionals organize an interrelated system of people and facilities that works together as a unit describes:

A) commercial insurance.
B) managed care.
C) systemized healthcare.
D) preventive care.

Question 21

The two most common types of managed care organizations are ___________ and ____________.

Question 22

The ____________________ model HMO is similar to an IPA,except that the organization contracts directly with individual providers.

Question 23

HMOs normally do not have ____________________ or plan limits.

Question 24

A ____________________ is used in managed care plans to reduce unnecessary inpatient/outpatient services.

Question 25

List the three main objectives of HIPAA.

Question 26

When a patient is sent to another provider (often a specialist)with the intent of rendering an expert opinion only,this is a/an ____________________.(Hint: Total care is not transferred.)

Question 27

A process used by health insurance companies to control healthcare costs,similar to preauthorization,is ____________________.

Question 28

One primary function of a managed care organization (MCO)is to establish a list of covered benefits tied to managed care rules.

Question 29

A "hybrid" type of managed care (also called an open-ended HMO)that allows patients either to use their HMO provider or to go outside the plan and use a provider of their choices is a/an ____________________.

Question 30

A request by a healthcare provider for a patient under his or her care to be treated by another provider,usually a specialist,is a/an ____________________.(Hint: Total care is often transferred.)

Question 31

One of the more popular types of MCO in this country is the preferred provider organization (PPO).

Question 32

Members of an HMO normally pay only a relatively small fee (called a copayment)each time they visit their healthcare provider.

Question 33

The new healthcare reform bill promotes __________.

Question 34

MCOs tend to focus on ____________________ care,or keeping the patient well,thus avoiding expensive treatment later on.

Question 35

____________________ pertains to medical necessity and appropriateness only and does not,in all instances,guarantee payment.

Question 36

Under the federal HMO act,an entity must have five characteristics to call itself an HMO.

Question 37

With a point-of-service type HMO,patients are allowed to go outside the plan and use any provider they choose.

Question 38

A predominant,standard-setting nonprofit organization that evaluates and accredits healthcare organizations in the United States is ____________________.

Question 39

The predominant accrediting body in managed care that measures,assesses,and reports on the quality of care and service in MCOs is _____________.

Question 40

Explain how the Affordable Care Act relates to managed care.

Question 41

Although there are several advantages to the managed care type of healthcare,there are no disadvantages.

Question 42

One of the major goals of the Affordable Care Act is to provide quality,affordable care for all Americans.

Question 43

Healthcare reform will likely eliminate most managed care arrangements.

Question 44

Managed care has had little impact on healthcare in general in the United States.

Question 45

HIPAA requires all employers to provide healthcare coverage for their employees.

Question 46

The future of managed care is clear-cut;it is predicted that it will totally eliminate traditional healthcare in 10 years.

Question 47

The purpose of a consultation usually is to obtain an expert opinion only,and care of the patient is not relinquished to the consulting provider.

Question 48

A referral is exactly the same as a consultation.

Question 49

Precertification is a process people must go through to become eligible to join an HMO.

Question 50

One advantage of an MCO is that it never has to be accredited.