Deck 6: Managed Care Organizations

Question 1

The _________________ is similar to the group model HMO, but it will contract with multiple multispecialty groups to provide care for their members.

A) Group Model HMO
B) Independent Practice Association
C) Network Model HMO
D) Preferred Provider Organization
E) Exclusive Provider Organization

Answer 1

C

Question 2

In a(n) __________, the HMO will directly employ the physicians and various other healthcare professionals to provide healthcare services to their members.

A) Group Model HMO
B) Staff Model
C) Network Model HMO
D) Integrated Delivery System
E) Exclusive Provider Organization

Answer 2

B

Question 3

Which of the following can be a primary care physician (PCP)?

A) Family physician
B) Pediatrician
C) Internist
D) Obstetrician/gynecologist
E) All of these are correct.

Answer 3

E

Question 4

_______________________ is similar to the PPO, except that the patients enrolled in the plan are to receive healthcare services only from the network providers.

A) HMO
B) PPO
C) POS
D) EPO
E) IDS

Question 5

Most Integrated Delivery Systems (IDSs) are comprised of multiple facilities that can provide care along the continuum of care for the patient and their family. They include all of the following, except:

A) physician's offices.
B) ambulatory surgical centers.
C) outpatient clinics.
D) homecare agencies.

Question 6

These groups manage the care delivered by multiple providers and multiple facilities. The _______ will generally provide the full spectrum of care from physician services, acute care, ambulatory care services, and services of a skilled nursing facility.

A) IDS
B) IPO
C) GPWW
D) None of these is correct.

Question 7

The American College of Medical Quality has defined ________________ as "accepted healthcare services and supplies provided by healthcare entities, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with applicable standard of care."

A) medical necessity
B) utilization management
C) managed care
D) preventative care

Question 8

_______________________ is the evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilitates these under the provisions of the applicable health benefits plan.

A) MSA
B) Utilization management
C) Managed care
D) Preventative care

Question 9

__________ is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs.

A) MSO
B) Utilization management
C) Case management
D) Contract management

Question 10

__________ is not based on a specific procedure or hospital stay, as it is based on a per-member-per-month (PMPM) methodology.

A) Capitated payment
B) Block payment
C) Transfer payment
D) Bundled payment

Question 11

The _____________________ methodology can be applied to procedures that are associated with technical components. This is a lump-sum payment that can be distributed among all the physicians who either performed the procedure or interpreted the results of the procedure.

A) retrospective payment
B) block payment
C) global payment
D) capitated payment

Question 12

_______________________ is a very important part of the episode-of-care payment method. It requires that the providers of care, along with the plans, be as precise as possible in projecting expenditures in order to negotiate a contract that will cover the costs involved in treating the members of the plan.

A) Contract management
B) Capitation
C) Block payment
D) Utilization management
E) None of these is correct.

Question 13

The NCQA offers ___________________________ that focus on the employers, health plans, patients, and consumers to allow them to make informed healthcare decisions based on quality.

A) voluntary surveys
B) patient satisfaction questionnaires
C) recognition programs
D) certification programs

Question 14

A Coordinated Care Plan (CCP) includes a network of providers that are under a contractual arrangement to deliver the benefit package that is approved by:

A) CMS.
B) NCQA.
C) ACOs.
D) HEDIS.

Question 15

According to CMS, there are three categories that are related to targeted populations. These include all of the following, except:

A) Chronic Conditions SNPs.
B) Dual-eligible SNPs.
C) Institutionalized SNPs.
D) Non-chronic Condition SNPs.

Question 16

_________________________ combine a high deductible MA plan and a medical savings account that is used to pay for qualified medical expenses for the account holder.

A) Employer Group Health Plans
B) Private Fee-for-Service Plans
C) Medicare Medical Savings Account Plans
D) Religious Fraternal Benefit Plans

Question 17

A(n) ________________________ is a group plan that is sponsored by an employer or labor organization who can enroll their members in one of three plan options.

A) Employer Group Health Plan
B) Private Fee-for-Service Plan
C) Medicare Medical Savings Account Plan
D) Religious Fraternal Benefit Plan

Question 18

The ___________________________ are MA plans offered to a society that is limited to only the members of the society.

A) Employer Group Health Plans
B) Private Fee-for-Service Plans
C) Medicare Medical Savings Account Plans
D) Religious Fraternal Benefit Plans

Question 19

The IPA is comprised of an organized group of physicians who get together to form the IPA, and they give up ownership of their individual practices.

Question 20

A POS plan is the fastest growing plan in the managed care marketplace, and it gives the patient the most flexibility in choices for care.

Question 21

The PCP does not control access for patients or guide them through the services that they may need. They do not ensure that they are managing costs based on the plan guideline and network providers.

Question 22

A Prior Authorization (PA) is also considered a cost control measure for the MCOs.

Question 23

The Case Manager helps the patient identify appropriate out-of-network providers that fit the patient's needs and to ensure the continuum of care for the patient is uninterrupted by having to change providers.

Question 24

In contract management, if a plan or provider underestimates the utilization for the population they are serving, the outcome will be a negative one in that the utilization will be higher than projected, and the plan or provider loses money.

Question 25

NCQA is an accrediting entity as identified by the Department of Health and Human Services (HHS) for Qualified Health Plan. NCQA is a private, not-for-profit organization that focuses on accreditation, certification, and recognition of health plans and reports on the overall quality of managed care plans in the United States.