Deck 4: Managed Care

Question 1

Medicare Advantage (formerly Medicare + Choice) is _________________.

A) a Medicare managed care program
B) the use of supplemental insurance to pay for medical expenses not covered under Medicare
C) a program for physicians that allows them to choose to participate in Medicare or not
D) a federal health care program created by the Patient Protection and Affordable Care Act (PPACA) to replace and expand traditional Medicare

Answer 1

a Medicare managed care program

Question 2

A core set of standard performance measures for managed care in the areas of quality, access and patient satisfaction, membership, utilization, finance, and health plan management is named ______________.

A) MCO
B) ISDN
C) HEDIS
D) SPM-MC

Answer 2

HEDIS

Question 3

Determining which insurance is the primary payer and assuring that no more than 100 percent of the charges are paid to the provider and/or reimbursed to the patient is called ______________.

A) capitation
B) coinsurance
C) gatekeeping
D) coordination of benefits

Answer 3

coordination of benefits

Question 4

The amount of medical expenses that insureds must pay each year from their own pockets before the plan will reimburse them is called the ______________.

A) coinsurance
B) deductible
C) copayment
D) per annum

Question 5

One aspect of Medicare managed care is that _____________.

A) premiums to HMOs are risk-adjusted based on patient diagnoses
B) Medicare pays physicians directly through fee-for-service arrangements
C) additional premiums are paid to all HMOs who employ certified wellness coordinators
D) hospitals with Joint Commission accreditation are not deemed to meet the Conditions of Participation for Managed Care

Question 6

The managed care primary care provider (PCP) who coordinates all patient health care needs and decides what, if any, additional care or testing is required is acting as a(n) ______________.

A) coinsurer
B) network
C) gatekeeper
D) indemnifier

Question 7

Individuals who are the primary recipients of the managed care insurance benefit within a managed care organization are referred to as _______________.

A) patients
B) dependents
C) subscribers
D) beneficiaries

Question 8

The spouse or child of the primary recipient of the managed care insurance benefit within a managed care organization is referred to as a _____________.

A) contract
B) dependent
C) subscriber
D) beneficiary

Question 9

Mid-level providers are often used in managed care to provide illness-related services to patients; they include ____________.

A) physicians
B) case managers
C) health educators
D) nurse practitioners

Question 10

A managed care organization (MCO) that undergoes evaluation of its ability to perform as an insurance provider will request accreditation from _______________.

A) CMS
B) NCQA
C) AAAHC
D) The Joint Commission

Question 11

The authorization to receive a specific health service from a specific health provider is called a(n) ___________.

A) transfer
B) referral
C) encounter
D) remittance

Question 12

The determination as to whether a person is allowed to receive care under a managed care organization contract is called ____________.

A) eligibility
B) enrollment
C) entitlement
D) case management

Question 13

The process of review to approve a provider, such as a physician, who applies to participate in a health plan is ______________.

A) evaluation
B) regulation
C) credentialing
D) accreditation

Question 14

Ensuring that a provider is not underutilizing services and compromising the health of managed care members or overutilizing services and creating unnecessary expense is ________________.

A) service regulation
B) financial supervision
C) enrollment managemen
D) economic credentialing

Question 15

The 20 percent expense that is the responsibility of the insured under an indemnity insurance policy is called _______________.

A) coinsurance
B) copayment
C) self-indemnity
D) point-of-service fee

Question 16

A ___________________________________________ is a mechanism by which an employer funds an account for its employees to pay for otherwise unreimbursed health care expenses.​

Question 17

All individuals eligible to receive care within the managed care organization (MCO) are referred to as residents.

Question 18

Medicare managed care plans receive payments under the Medicare Advantage program for enrollees who have both Part A and Part B coverage.

Question 19

Preventive care and wellness are a central focus of a health maintenance organization and most managed care organizations.

Question 20

In the staff model HMO, the HMO entity owns the facilities and arranges for health care through employed physicians, who are allowed to see only the particular HMO's patients.

Question 21

The Clinical Laboratory Improvement Amendments (CLIA) require that every laboratory possess a certificate to operate and that laboratories that fail to meet the operational standards or proficiency testing guidelines be sanctioned.

Question 22

Coordination of benefits (COB) allows excess reimbursement from health plans to providers to be refunded to the patient.

Question 23

A managed care organization that meets TJC or AAAHC standards is deemed to meet NCQA standards.

Question 24

The managed care organization (MCO) produces its revenue by selling an insurance product and must reimburse providers for services delivered to members.

Question 25

A provider's panel is the group of patients who have chosen the provider as their primary care provider (PCP).

Question 26

Capitation is the payment of a fixed dollar amount for each covered person for the provision of a predetermined set of health care services for a specific period of time.

Question 27

The MCO negotiates per diem rates with individual physicians.

Question 28

A fee schedule is a predetermined rate for each procedure, visit, or service. Negotiating a fee schedule allows more consistent budgeting of payment dollars by the managed care organization.

Question 29

The resource-based relative value scale (RBRVS) system is an example of per diem reimbursement.

Question 30

When a provider agrees to see managed care organization (MCO) patients and to subtract a certain percentage from the regular fee-for-service rate, this is called discounted charges.

Question 31

An employee who is injured on the job must receive care from a provider selected by the workers' compensation carrier.

Question 32

Per diem means "paid by the day or at a daily rate."

Question 33

An MCO is built on contracted relationships. An index of contracts, including expira-tion dates and any proposed contract changes, is maintained to be sure all contracts remain valid and at an optimal level of reimbursement.

Question 34

A(n) ___________________________ is a Medicare pilot payment program in which an organization composed of a local entity and a related set of providers can be held responsible for the cost and quality of care through financial rewards for good performance based on comprehensive quality and spending measurement and monitoring.​

Question 35

​______________________________ are disease groupings based on ICD codes from both inpatient admissions and outpatient visits that are used to risk-adjust Medicare payments to Medicare Advantage MCOs.

Question 36

Match each description with the correct item

- Insurance entity that contracts with providers to create a network, resulting in lower costs of services to patients

A) Health maintenance organization
B) Integrated delivery system
C) Managed indemnity plan
D) Health savings account
E) Point of service plan
F) Preferred provider organization
G) Flexible spending account
H) Health reimbursement arrangement

Question 37

Match each description with the correct item

- Group of facilities that contract together to provide comprehensive services to patients

A) Health maintenance organization
B) Integrated delivery system
C) Managed indemnity plan
D) Health savings account
E) Point of service plan
F) Preferred provider organization
G) Flexible spending account
H) Health reimbursement arrangement

Question 38

Match each description with the correct item

- Insurance entity that provides or arranges services for a covered population who prepays a fixed premium

A) Health maintenance organization
B) Integrated delivery system
C) Managed indemnity plan
D) Health savings account
E) Point of service plan
F) Preferred provider organization
G) Flexible spending account
H) Health reimbursement arrangement

Question 39

Match each description with the correct item

- Insurance plan that reimburses the insured for expenses incurred, but incorporates some managed care principles to help control costs

A) Health maintenance organization
B) Integrated delivery system
C) Managed indemnity plan
D) Health savings account
E) Point of service plan
F) Preferred provider organization
G) Flexible spending account
H) Health reimbursement arrangement

Question 40

Match each description with the correct item

- Insurance plan that combines prepaid health services with network providers, creating levels of out-of-pocket cost options for the insured

A) Health maintenance organization
B) Integrated delivery system
C) Managed indemnity plan
D) Health savings account
E) Point of service plan
F) Preferred provider organization
G) Flexible spending account
H) Health reimbursement arrangement

Question 41

Match each description with the correct item

- Fund set up by an employee that is not taxed when the employee withdraws from the account for medical expenses. Amounts left in the account at the end of the benefit year roll over to the next year. Withdrawals for nonmedical expenses are subject to income tax and a 10-percent penalty.

A) Health maintenance organization
B) Integrated delivery system
C) Managed indemnity plan
D) Health savings account
E) Point of service plan
F) Preferred provider organization
G) Flexible spending account
H) Health reimbursement arrangement

Question 42

Match each description with the correct item

- Mechanism by which an employer funds an account for its employees to pay for otherwise unreimbursed health care expenses; some employers allow employees to continue to access funds after retirement

A) Health maintenance organization
B) Integrated delivery system
C) Managed indemnity plan
D) Health savings account
E) Point of service plan
F) Preferred provider organization
G) Flexible spending account
H) Health reimbursement arrangement

Question 43

Match each description with the correct item

- Tax-free money an employee sets aside to use during a specified period for health care expenses; funds cannot be used for nonmedical purposes; funds not used are returned to the employer at the end of the benefit period

A) Health maintenance organization
B) Integrated delivery system
C) Managed indemnity plan
D) Health savings account
E) Point of service plan
F) Preferred provider organization
G) Flexible spending account
H) Health reimbursement arrangement

Question 44

Match each description with the correct item

- HMO entity that owns the facilities and arranges for health care through employed providers

A) Mixed model HMO
B) Independent practice association model HMO
C) Group model HMO
D) Staff model HMO
E) Network model HMO

Question 45

Match each description with the correct item

- HMO that has an exclusive contract with one multi-specialty medical group that provides all physician services

A) Mixed model HMO
B) Independent practice association model HMO
C) Group model HMO
D) Staff model HMO
E) Network model HMO

Question 46

Match each description with the correct item

- HMO that contracts with more than one physician group, hospital, and other facilities to provide a comprehensive health care package

A) Mixed model HMO
B) Independent practice association model HMO
C) Group model HMO
D) Staff model HMO
E) Network model HMO

Question 47

Match each description with the correct item

- HMO model that was developed as a way for solo practice physicians to participate in the managed care market

A) Mixed model HMO
B) Independent practice association model HMO
C) Group model HMO
D) Staff model HMO
E) Network model HMO

Question 48

Match each description with the correct item

- HMO that operates within two or more different types of organizational structures to provide flexibility to members and diversity of income to the HMO

A) Mixed model HMO
B) Independent practice association model HMO
C) Group model HMO
D) Staff model HMO
E) Network model HMO

Question 49

Match each description with the correct item

- Each part of the entity may be individually accredited by this organization.

A) AAAHC
B) TJC
C) NCQA
D) URAC

Question 50

Match each description with the correct item

- This organization offers Health Plan accreditation for HMOs and Health Network accreditation for PPOs.

A) AAAHC
B) TJC
C) NCQA
D) URAC

Question 51

Match each description with the correct item

- This organization accredits managed care organizations and related services, including health plan accreditation, wellness and health promotion, managed behavioral health care organizations, and disease management.

A) AAAHC
B) TJC
C) NCQA
D) URAC

Question 52

Match each description with the correct item

- This organization accredits HMOs at each clinic site, but not as an HMO.

A) AAAHC
B) TJC
C) NCQA
D) URAC

Question 53

?Describe the following activities that are completed through utilization management: preadmission certification, preauthorization, concurrent review and discharge planning.

Question 54

?Describe three criteria involved with credentialing.

Question 55

Describe what a POS plan is and how it helps plan members with the ability to choose their services.

Question 56

Give examples of various types of voluntary accreditation an MCO could choose.?