Question 1

Contracts between the physician and managed care organization (MCO) are generally negotiated by the:
A)medical office specialist.
B)physician or upper management.
C)attorney.
D)account manager or business manager.

Accepted Answer

The contracts between the physician and MCO are typically negotiated by the physician or upper management. This is because they are the ones who have the medical knowledge and expertise to determine the terms of the contract and negotiate any issues that may arise. While an attorney may be involved, they primarily provide legal advice and guidance rather than negotiating the contract itself. The medical office specialist and account/business manager may also have a role in the process, but they are typically not the primary negotiators.

Question 2

A managed care contract is considered a legal document between the:
A)provider and insurer.
B)provider and patient.
C)patient and insurer.
D)insurer and employer.

Accepted Answer

provider and insurer.

Question 3

Under a discounted fee-for-service arrangement, covered services are compensated at a:
A)discounted per-diem rate.
B)per-member-per-month rate.
C)reduced percentage of usual and customary charges.
D)reduced per-case rate.

Accepted Answer

Under a discounted fee-for-service arrangement, covered services are compensated at a reduced percentage of usual and customary charges. This means that the provider will receive a lower payment compared to their usual fee, but it is still a fee-for-service arrangement where the provider is reimbursed for each covered service rendered to the patient. The other options (per-diem rate, per-member-per-month rate, and per-case rate) are different payment methods that are not typically used under a discounted fee-for-service arrangement.

Question 4

The schedule of benefits section of a managed care contract lists the:
A)deductible and coinsurance amounts that patients must pay.
B)providers in the contracted network.
C)medical services covered under the managed care plan.
D)benefits of participating in the managed care plan.

Accepted Answer

The schedule of benefits section of a managed care contract lists the medical services covered under the managed care plan.

Question 5

Providers are likely to agree to discounted fee-for-service contracts because they result in a(n):
A)decrease in taxes paid by the physician.
B)increase in the number of patients referred to the physician.
C)decrease in paperwork required to file claims.
D)fewer administrative tasks for the medical office assistant.

Accepted Answer

Discounted fee-for-service contracts can result in an increase in the number of patients referred to the physician, which can, in turn, lead to increased revenue for the provider. This is because the discounted fees may make the provider's services more affordable and attractive to patients. The other options (decrease in taxes, decrease in paperwork, and fewer administrative tasks) are not necessarily related to discounted fee-for-service contracts.

Question 6

A managed care contract will include a:
A)list of patients covered by the plan.
B)list of physicians in the network.
C)description of what types of employer groups are offered coverage.
D)description of how the physician will be paid for services.

Accepted Answer

A managed care contract will typically include a description of how the physician will be paid for services. The other choices may or may not be included in the contract, but they are not central to the financial arrangement between the physician and the managed care organization.

Question 7

Under a contract based on a per-case or per-visit rate of compensation, the provider is paid a predetermined rate for each:
A)enrolled patient.
B)episode of care.
C)diagnosis code.
D)service provided.

Accepted Answer

The answer of Under a contract based on a per-case...

Question 8

RBRVS stands for:
A)resource-based relative value scale.
B)resource-based rates of valued services.
C)rates by resources and value scale.
D)relative buying rates for valued services.

Accepted Answer

The answer of RBRVS stands for:
A)resource-based relative value scale.
B)resource-based rates...

Question 9

A contract with which of the following payment terms can result in an increased financial risk to the provider?
A)Capitation
B)Percentage of premiums
C)Fee-for-service
D)Discounted fee-for-service

Accepted Answer

The answer of A contract with which of the following...

Question 10

Which of the following is NOT a common type of payment arrangement in a managed care contract?
A)Discounted fee-for-service
B)Usual and customary
C)Capitation
D)Per case

Accepted Answer

The answer of Which of the following is NOT a...

Question 11

A managed care contract should clearly state all of the following EXCEPT:
A)how much the physician will be paid for services.
B)when payment should be received from the MCO.
C)the time limit for submitting claims to the MCO.
D)the list of employers with MCO contracts.

Accepted Answer

The list of employers with MCO contracts is not relevant to the specific terms of the contract between the physician and the MCO. The contract should clearly state the payment amount, payment timing, and claims submission deadline.

Question 12

Provisions included in a managed care contract with a provider include:
A)what is expected of the provider.
B)time limits for submitting claims.
C)reimbursement amounts.
D)a listing of eligible patients

Accepted Answer

The answer of Provisions included in a managed care contract...

Question 13

Which type of payment method creates an incentive to provide more preventive care?
A)Capitation
B)Per diem
C)Per case
D)Discounted fee-for-service

Accepted Answer

The answer of Which type of payment method creates an...

Question 14

A provider who enters into a contract with an MCO is referred to as a(n):
A)active provider.
B)MCO provider.
C)participating provider.
D)permanent provider.

Accepted Answer

A participating provider is a healthcare provider who has a contract with an MCO to provide services to its members at discounted rates. This type of provider is also known as an "in-network" provider, and they agree to follow the MCO's rules and regulations in exchange for access to the MCO's member population.

Question 15

MCOs develop a network by contracting with:
A)physicians.
B)facilities.
C)pharmacies.
D)all of the above.

Accepted Answer

The answer of MCOs develop a network by contracting with:
A)physicians.
B)facilities.
C)pharmacies.
D)all...

Question 16

With respect to a managed care contract, a medical office specialist is responsible for understanding the:
A)administrative requirements of submitting claims and time frames for payment.
B)process used to determine the fee schedule.
C)MCO's plans for advertising and promoting the provider network.
D)ownership and financial status of the MCO.

Accepted Answer

The answer of With respect to a managed care contract,...

Question 17

According to some contract terms, if an MCO does not pay a claim within the time limit specified in the contract, the provider may be able to:
A)bill the patient directly.
B)charge the usual and customary fee instead of the discounted fee.
C)take legal action against the MCO.
D)terminate the MCO contract after filing a written notice of intention.

Accepted Answer

If an MCO fails to pay a claim within the agreed-upon time frame, the provider may be entitled to charge the usual and customary fee instead of the discounted fee. This is known as the "prompt payment" provision, and it is designed to ensure that providers are fairly compensated for their services in a timely manner. Billing the patient directly or terminating the MCO contract are not typically options in this situation, and legal action would only be pursued as a last resort.

Question 18

The benefits of a managed care contract to the provider include:
A)keeping costs down.
B)bringing more patients to the practice.
C)adding opportunities for staff development.
D)increasing administrative duties.

Accepted Answer

The answer of The benefits of a managed care contract...

Question 19

An increase in patient volume often results from:
A)discounted fee-for-service contracts.
B)per diem and per case contracts.
C)percentage of premium and capitation contracts.
D)capitation contracts.

Accepted Answer

The answer of An increase in patient volume often results...

Question 20

Fee schedules in managed care contracts are increasingly based on:
A)Medicare's resource-based relative value scale (RBRVS) and conversion factor.
B)Medicare's resource-based relative value scale (RBRVS) with a different conversion factor.
C)the HMO's per-member-per-month guidelines.
D)usual and customary charges adjusted by geographic area.

Accepted Answer

The answer of Fee schedules in managed care contracts are...

Quiz 3: Understanding Managed Care: Medical Contracts and Ethics

Contracts between the physician and managed care organization (MCO) are generally negotiated by the: A)medical office specialist. B)physician or upper management. C)attorney. D)account manager or business manager.

A managed care contract is considered a legal document between the: A)provider and insurer. B)provider and patient. C)patient and insurer. D)insurer and employer.

Under a discounted fee-for-service arrangement, covered services are compensated at a: A)discounted per-diem rate. B)per-member-per-month rate. C)reduced percentage of usual and customary charges. D)reduced per-case rate.

The schedule of benefits section of a managed care contract lists the: A)deductible and coinsurance amounts that patients must pay. B)providers in the contracted network. C)medical services covered under the managed care plan. D)benefits of participating in the managed care plan.

A managed care contract will include a: A)list of patients covered by the plan. B)list of physicians in the network. C)description of what types of employer groups are offered coverage. D)description of how the physician will be paid for services.

Under a contract based on a per-case or per-visit rate of compensation, the provider is paid a predetermined rate for each: A)enrolled patient. B)episode of care. C)diagnosis code. D)service provided.

RBRVS stands for: A)resource-based relative value scale. B)resource-based rates of valued services. C)rates by resources and value scale. D)relative buying rates for valued services.

A contract with which of the following payment terms can result in an increased financial risk to the provider? A)Capitation B)Percentage of premiums C)Fee-for-service D)Discounted fee-for-service

Which of the following is NOT a common type of payment arrangement in a managed care contract? A)Discounted fee-for-service B)Usual and customary C)Capitation D)Per case

A managed care contract should clearly state all of the following EXCEPT: A)how much the physician will be paid for services. B)when payment should be received from the MCO. C)the time limit for submitting claims to the MCO. D)the list of employers with MCO contracts.

Provisions included in a managed care contract with a provider include: A)what is expected of the provider. B)time limits for submitting claims. C)reimbursement amounts. D)a listing of eligible patients

Which type of payment method creates an incentive to provide more preventive care? A)Capitation B)Per diem C)Per case D)Discounted fee-for-service

A provider who enters into a contract with an MCO is referred to as a(n): A)active provider. B)MCO provider. C)participating provider. D)permanent provider.

MCOs develop a network by contracting with: A)physicians. B)facilities. C)pharmacies. D)all of the above.

The benefits of a managed care contract to the provider include: A)keeping costs down. B)bringing more patients to the practice. C)adding opportunities for staff development. D)increasing administrative duties.

An increase in patient volume often results from: A)discounted fee-for-service contracts. B)per diem and per case contracts. C)percentage of premium and capitation contracts. D)capitation contracts.