Deck 9: Managed Care Impact on Healthcare Delivery

Question 1

Preferred Provider Organizations do not have a gatekeeper like the HMO so a member does not need a referral to see a specialist.

Answer 1

True

Question 2

Silent PPOs are unauthorized third parties outside the contract between the MCO and the physician that gain access to the MCO discount rates. Examples of these network rentals are automobile insurers or workmen's compensations insurers. They obtain the physician's rates from a database. The main insurer who has the contract with the physician does not provide the information to the physician and the third parties continue to benefit from the discounted rates. There are currently 14 states that prohibit them.

Answer 2

True

Question 3

Which of the following are cost control measures of managed care organizations?

A)Restrictions on provider choices.
B)Establishing a gate keeper or primary care provider as the coordinator of their patient's services.
C)A review of the different types of services being provided.
D)All statements are accurate.

Answer 3

All statements are accurate.

Question 4

As the types of MCOs have evolved over the years, the restrictions have lessened, but there is a financial penalty such as a higher copayment or higher deductible for choosing a provider outside of the network.

Question 5

Utilization review evaluates the appropriateness of the types of services provided.

Question 6

Why was the National Committee on Quality Assurance established?

A)To measure service and quality of care by analyzing data.
B)To measure, analyze and improve health care programs through a voluntary accrediting process.
C)To provide discounted fees and salaries of physicians who work in managed care.
D)All of the above are accurate.

Question 7

Health maintenance organizations (HMOS)are the oldest type of managed care. Members must see their primary care provider first in order to see a specialist.
.

Question 8

The concept of managed care has been evolving since the early 1930s.

Question 9

Medical loss ratio is the minimum amount of dollars a health care plan spends on providing care rather than administration.

Question 10

In some MCOs, the primary care provider is the fencekeeper of all of the care for the patient member.

Question 11

Point of Service Plans a type of HMO/PPO hybrid. They encourage plan members to seek but are not required to use a primary care provider who will become the gatekeeper of services. Members will receive lower fees if they use a gatekeeper model.

Question 12

Increasing numbers of states (16 in 2012)are using Managed Long Term Services and Supports (MLTSS), a CMS Medicaid program, as a strategy for expanding home- and community-based services to ensure quality and increase efficiency.

Question 13

The Affordable Care Act of 2010 mandates that health insurance companies must spend
80%-85% of their premium revenues on quality health care.

Question 14

Practice profiling is a type of employee performance review because the focus is to determine which provider also fits in with the organizational culture of the MCO.

Question 15

If a physician is an employee of a managed care organization, the MCO will pay the physician's salary and bonuses based on performance.

Question 16

The Independent Practice Association (IPA)is a type of Health Maintenance Organization (HMO)model that:

A)Negotiates with a group of physicians exclusively to perform services.
B)Contracts with a group of physicians who are in private practice to see managed care members at a prepaid rate per visit.
C)Hires physicians to work at a physical location.

Question 17

Carve outs are health care services that will not be paid by MCOs which could include experimental treatment, drug costs and behavioral health costs.

Question 18

A fee for service (FFS)system was the traditional health insurance plan that paid a fee for a provided service by the provider. This system increased the costs of healthcare throughout its history.

Question 19

Prospective utilization review is:

A)Decisions that are being made during the actual course of service such as additional surgery.
B)An evaluation of services once the services have been provided.
C)Examines specific provider patterns of practice.
D)Implemented before the service is actually performed by having the procedure authorized by the MCO.

Question 20

Managed care refers to the cost management of health care services utilization by controlling who the consumer sees and how much the service cost.

Question 21

When Medicare pays pay a premium per member that is based on the member's county of residence, it is called:

A)Risk plan
B)At risk plan
C)Carve out plan
D)None of the above

Question 22

Since the late 1980s, which organization has been reviewing and accrediting managed care organizations?

A)Medicare Deemed Status Association
B)American Health Association
C)American Medical Association
D)Accreditation Association for Ambulatory Care

Question 23

Medicare cost plans are:

A)A type of HMO
B)A type of PPO
C)Have similar rules to Medicare Advantage plans
D)All are correct

Question 24

What are physician hospital organizations?

A)They are healthcare providers that contract with MCOs to provide services to their members.
B)They restrict MCO members to a list of providers they can use for care.
C)They are the gatekeeper for all members' services.
D)All are correct

Question 25

What is the importance of the Health Employer Data and Information Set (HEDIS)?

Question 26

In managed care payments, another term for a per member per month policy is called:

A)Carve outs
B)Retrospective reimbursements
C)Capitation policy
D)Prospective reimbursement

Question 27

What are the three types of utilization reviews of managed care organizations?

Question 28

What are limited benefit plans?

A)They agree to act as the individual's primary care provider
B)They agree to provide Medicaid benefits in exchange for a payment from the state.
C)They only provide one or two Medicaid benefits.
D)All are correct

Question 29

What are the five common characteristics of managed care organizations?

Question 30

What are the three major types of managed care organization's remuneration plans to providers?

Question 31

Define the Health Maintenance Organization Model and list the different Health Maintenance Organization models.