Question 1

A medical office specialist works as a liaison between:
A)the provider and patient.
B)the provider and carrier.
C)the patient and employer.
D)the employer and carrier.

Accepted Answer

The answer of A medical office specialist works as a...

Question 2

Emergency services are warranted if the absence of immediate medical attention could result in:
A)placing the covered person's health in serious jeopardy.
B)serious impairment to bodily functions.
C)serious dysfunction of any bodily organ or part.
D)all of the above.

Accepted Answer

All of the options listed are reasons for emergency services to be warranted. Immediate medical attention is necessary to prevent serious harm to a person's health and bodily functions, as well as avoid dysfunction of any bodily organ or part.

Question 3

With MCOs, the business aspects of healthcare are not being controlled by:
A)physicians.
B)managers.
C)accountants.
D)actuaries.

Accepted Answer

The answer of With MCOs, the business aspects of healthcare...

Question 4

When a person has health insurance coverage through two or more plans, the determination of which plan will provide benefits as primary or secondary payer is known as:
A)case management.
B)benefit determination.
C)coordination of benefits.
D)coordination of services.

Accepted Answer

When a person has health insurance coverage through two or more plans, the determination of which plan will provide benefits as primary or secondary payer is known as coordination of benefits. This process ensures that the total payment received for services does not exceed the actual cost of care.

Question 5

Medically necessary services include all of the following EXCEPT services that are:
A)experimental, investigative, or unproven.
B)based on recognized standards of the specialty involved.
C)not solely for the convenience of a covered person or a healthcare provider.
D)accepted by the healthcare profession as appropriate and effective for the condition being treated.

Accepted Answer

Medically necessary services must be based on recognized standards of the specialty, accepted by the healthcare profession as appropriate and effective for the condition being treated, and not solely for the convenience of a covered person or healthcare provider. However, experimental, investigative, or unproven services are not considered medically necessary.

Question 6

One aspect of healthcare reform that most people agree on is that:
A)the cost of healthcare delivery is likely to decrease in the next decade.
B)managed care will not be a long-term trend.
C)the specific scope of necessary changes has been determined.
D)reform needs to address issues of cost, access, and quality of care.

Accepted Answer

The answer of One aspect of healthcare reform that most...

Question 7

The contract issued by a payer, the plan document, or any other legally enforceable instrument under which a covered person may be entitled to covered services is called:
A)the schedule of benefits.
B)the benefit plan.
C)covered services.
D)contracted services.

Accepted Answer

The benefit plan is the contract or legally enforceable instrument that outlines what services are covered for a covered person. The schedule of benefits outlines the specific covered services and the amount the payer will pay for each service. Covered services refer to the actual medical services or procedures that are covered under the plan. Contracted services refers to the services provided by a healthcare provider who has a contractual agreement with the payer to provide services to covered persons.

Question 8

The organization that awards accreditation to managed care organizations is the:
A)Centers for Medicare and Medicaid Services (CMS).
B)National Center for Competency Testing (NCCT).
C)National Committee for Quality Assurance (NCQA).
D)World Health Organization (WHO).

Accepted Answer

The National Committee for Quality Assurance (NCQA) is the organization that awards accreditation to managed care organizations. The Centers for Medicare and Medicaid Services (CMS) is a government agency responsible for administering those programs, but they do not award accreditation. The National Center for Competency Testing (NCCT) is an organization that offers certification exams for healthcare professionals, but they do not award accreditation. The World Health Organization (WHO) is a global organization focused on public health, but they do not award accreditation to managed care organizations.

Question 9

The following is true of a managed care system:

Accepted Answer

Both a and c.

Question 10

Through a credentialing process, a managed care organization (MCO) evaluates a provider's:
A)medical credentials.
B)service fees.
C)workplace environment.
D)all of the above.

Accepted Answer

The answer of Through a credentialing process, a managed care...

Question 11

In cases of fraudulent billing:
A)only the physician can be held liable.
B)the physician can never be held liable.
C)the medical office specialist can be held liable.
D)the medical office specialist can never be held liable.

Accepted Answer

Both the physician and the medical office specialist can be held liable for fraudulent billing, depending on their level of involvement in the fraudulent activity. It is important for all members of the healthcare team to uphold ethical and legal standards in billing practices.

Question 12

The credentialing process of a managed care organization (MCO) will examine each physician's background for evidence of all of the following except:
A)criminal activity.
B)disciplinary actions.
C)malpractice history.
D)salary history.

Accepted Answer

The answer of The credentialing process of a managed care...

Question 13

Services provided to treat a medical condition that involves the sudden onset of acute symptoms of sufficient severity to threaten a person's life or health are:
A)urgent care.
B)medical care.
C)hospital care.
D)emergency care.

Accepted Answer

Emergency care is specifically designed to treat medical conditions that pose an immediate threat to a person's health or life. Urgent care, medical care, and hospital care may also provide treatment for acute symptoms, but emergency care is necessary when the situation is critical and requires immediate attention.

Question 14

The maximum allowable fee payable for the provision of a particular contracted service by a physician is called the:
A)reimbursement rate.
B)negotiated fee.
C)fee maximum.
D)capitation rate.

Accepted Answer

The maximum allowable fee payable for a contracted service by a physician is called the fee maximum. This is the highest amount that an insurance company will pay for a specific medical service.

Question 15

In plans that require the primary care physician (PCP) to play a gatekeeper role, the PCP is given incentives to:
A)expand office hours and/or staff to permit more patients to be seen each day.
B)make frequent referrals to contracted network specialists.
C)see as many patients each day as possible, even if this means less time with each patient.
D)treat the patient as much as possible and not refer him/her to a specialist unless absolutely necessary.

Accepted Answer

The answer of In plans that require the primary care...

Question 16

An MCO may contract with a physician whose background is questionable in order to:
A)contract with all the providers in a given area.
B)make the network as large as possible.
C)ensure that all specialties are available in the network.
D)An MCO would never contract with a physician who has a questionable reputation.

Accepted Answer

The answer of An MCO may contract with a physician...

Question 17

With respect to National Committee for Quality Assurance (NCQA) accreditation:
A)MCOs must be accredited to operate.
B)MCOs have all asked to be accredited, but some do not qualify.
C)some MCOs are accredited, and some are not.
D)accredited MCOs are always better than nonaccredited MCOs.

Accepted Answer

While many MCOs choose to seek NCQA accreditation as a way to demonstrate their commitment to quality and attract customers, it is not mandatory for their operation. As such, some MCOs are accredited, and some are not. Accreditation is a marker of quality, but it is not a guarantee that an MCO is better than a non-accredited MCO.

Question 18

The healthcare delivery system involves a relationship between:
A)patients and providers.
B)providers and third-party payers.
C)patients and third-party payers.
D)patients, providers, and third-party payers.

Accepted Answer

The answer of The healthcare delivery system involves a relationship...

Question 19

Business values that are being incorporated in medical practices as a result of managed care include a(n):
A)emphasis on the doctor-patient relationship.
B)return to fee-for-service payments.
C)focus on efficiency, cost reduction, and profit.
D)focus on administrative requirements and paperwork.

Accepted Answer

The answer of Business values that are being incorporated in...

Question 20

In a system based on managed care, the patient's choice of provider is:
A)dictated by his or her geographic location.
B)dictated by his or her income.
C)more limited than under a traditional fee-for-service structure.
D)less limited than under a traditional fee-for-service structure.

Accepted Answer

The answer of In a system based on managed care,...

Quiz 3: Understanding Managed Care: Medical Contracts and Ethics

A medical office specialist works as a liaison between: A)the provider and patient. B)the provider and carrier. C)the patient and employer. D)the employer and carrier.

Emergency services are warranted if the absence of immediate medical attention could result in: A)placing the covered person's health in serious jeopardy. B)serious impairment to bodily functions. C)serious dysfunction of any bodily organ or part. D)all of the above.

With MCOs, the business aspects of healthcare are not being controlled by: A)physicians. B)managers. C)accountants. D)actuaries.

When a person has health insurance coverage through two or more plans, the determination of which plan will provide benefits as primary or secondary payer is known as: A)case management. B)benefit determination. C)coordination of benefits. D)coordination of services.

The contract issued by a payer, the plan document, or any other legally enforceable instrument under which a covered person may be entitled to covered services is called: A)the schedule of benefits. B)the benefit plan. C)covered services. D)contracted services.

The organization that awards accreditation to managed care organizations is the: A)Centers for Medicare and Medicaid Services (CMS). B)National Center for Competency Testing (NCCT). C)National Committee for Quality Assurance (NCQA). D)World Health Organization (WHO).

The following is true of a managed care system:

Through a credentialing process, a managed care organization (MCO) evaluates a provider's: A)medical credentials. B)service fees. C)workplace environment. D)all of the above.

In cases of fraudulent billing: A)only the physician can be held liable. B)the physician can never be held liable. C)the medical office specialist can be held liable. D)the medical office specialist can never be held liable.

The credentialing process of a managed care organization (MCO) will examine each physician's background for evidence of all of the following except: A)criminal activity. B)disciplinary actions. C)malpractice history. D)salary history.

Services provided to treat a medical condition that involves the sudden onset of acute symptoms of sufficient severity to threaten a person's life or health are: A)urgent care. B)medical care. C)hospital care. D)emergency care.

The maximum allowable fee payable for the provision of a particular contracted service by a physician is called the: A)reimbursement rate. B)negotiated fee. C)fee maximum. D)capitation rate.

With respect to National Committee for Quality Assurance (NCQA) accreditation: A)MCOs must be accredited to operate. B)MCOs have all asked to be accredited, but some do not qualify. C)some MCOs are accredited, and some are not. D)accredited MCOs are always better than nonaccredited MCOs.

The healthcare delivery system involves a relationship between: A)patients and providers. B)providers and third-party payers. C)patients and third-party payers. D)patients, providers, and third-party payers.

Business values that are being incorporated in medical practices as a result of managed care include a(n): A)emphasis on the doctor-patient relationship. B)return to fee-for-service payments. C)focus on efficiency, cost reduction, and profit. D)focus on administrative requirements and paperwork.

In a system based on managed care, the patient's choice of provider is: A)dictated by his or her geographic location. B)dictated by his or her income. C)more limited than under a traditional fee-for-service structure. D)less limited than under a traditional fee-for-service structure.