Deck 11: The Blue Plans, Private Insurance, and Managed Care Plans

Question 1

A program that offers a combination of HMO-style cost management and PPO-style freedom of choice is a/an

A) point-of-service (POS) plan.
B) exclusive provider organization (EPO).
C) managed care organization (MCO).
D) physician provider group (PPG).

Answer 1

point-of-service (POS) plan.

Question 2

Benefits under the HMO Act fall under two categories: ____________________ health services and supplemental health services.

Answer 2

basic

Question 3

A significant contribution to HMO development was the

A) CIGNA plan.
B) Kaiser Permanente plan.
C) Health Maintenance Organization Act of 1973.
D) Omnibus Budget Reconciliation Act.

Answer 3

Health Maintenance Organization Act of 1973.

Question 4

When an HMO is paid a fixed amount for each patient served without considering the actual number or nature of services provided to each person, this is known as

A) fee-for-service.
B) capitation.
C) usual charges.
D) customary fees.

Question 5

A primary care physician who controls patient access to specialists is called a/an ____________________.

Question 6

In an independent practice association (IPA), physicians are

A) paid salaries by their own independent group.
B) paid salaries by the practice association.
C) not employees and are not paid salaries.
D) not paid until the end of the year in which services were rendered.

Question 7

When a physician sees a patient more than is medically necessary, it is called

A) buffing.
B) turfing.
C) churning.
D) stirring.

Question 8

What is the correct procedure to collect a copayment on a managed care plan?

A) There is no copayment with a managed care plan.
B) Bill the plan for the copayment.
C) Bill the patient for the copayment.
D) Collect the copayment when the patient arrives for the office visit.

Question 9

An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an

A) health maintenance organization (HMO).
B) managed care organization (MCO).
C) preferred provider organization (PPO).
D) exclusive provider organization (EPO).

Question 10

Kaiser Permanente's medical plan is a closed panel program, which means

A) only certain illnesses are covered.
B) it limits the patient's choice of personal physicians.
C) it limits the patient's choice of a hospital for emergency care.
D) services are provided on a fee-for-service basis.

Question 11

The abbreviation MCO stands for ______________________________.

Question 12

How does an HMO receive payment for the services its physicians provide?

A) Fee-for-service
B) Usual, customary, and reasonable charges
C) Allowable charges
D) Prepaid health plan

Question 13

Practitioners in an HMO program may come under peer review by a professional group called a

A) peer review group.
B) quality control group.
C) Quality Improvement Organization.
D) utilization management corporation.

Question 14

America's oldest privately owned, prepaid medical group is the

A) Ross-Loos Medical Group.
B) INA Healthplan, Inc.
C) Kaiser Permanente Medical Care Program.
D) Health Net HMO, Inc.

Question 15

What plan allows members of the Kaiser Permanente Medical Care Program to seek medical help from non-Kaiser physicians?

A) Health maintenance organization (HMO)
B) Point of service (POS)
C) Independent practice association (IPA)
D) Fee-for-service

Question 16

A physician-owned business that has the flexibility to deal with all forms of contract medicine and also offers its own plans is a/an

A) IPA.
B) PPO.
C) PPG.
D) POS.

Question 17

What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care?

A) Foundation for medical care
B) Physician provider group
C) Health care cost containment organization
D) Professional review organization

Question 18

Referral of a patient recommended by one specialist to another specialist is known as

A) primary care.
B) secondary care.
C) concurrent care.
D) tertiary care.

Question 19

The law states that an employer employing ____________________ or more persons may offer the services of an HMO clinic as an alternative health treatment plan for employees.

Question 20

How are physicians who work for a prepaid group practice model paid?

A) Salary paid by independent group
B) Salary paid by a health plan
C) Fee-for-service
D) Usual, customary, and reasonable charges

Question 21

When a certain percentage of the monthly capitation payment is held out of the premium fund to pay for operating an IPA, it is known as a/an ____________________.

Question 22

Ross-Loos Medical Group, America's oldest privately owned prepaid medical group, started in Texas.

Question 23

When a capitated patient's services go over a certain amount and the physician can begin asking the patient to pay (fee-for-service), this arrangement is provided in a ___________________ section of the managed care contract or agreement.

Question 24

Beginning in ______________, the passing of federal legislation in 2010 requires almost everyone to be insured or they will pay a fine.

Question 25

In a point-of-service (POS) program, members may choose to use a nonprogram provider at any time.

Question 26

Managed care plans never require a CMS-1500 claim form to be completed and submitted.

Question 27

The difference between an IPA and a PPG is that member physicians may not own an IPA, whereas a PPG is physician owned.

Question 28

When a managed care plan requires the primary care physician to seek approval before referring a patient to a specialist, it is called obtaining ____________________.

Question 29

In a staff model HMO, physicians are hired directly by the health plan that pays their salary.

Question 30

In times past, physicians in private practice billed indemnity insurance plans and professional services were reimbursed on a fee-for-service basis.

Question 31

In certain managed care plans there is an incentive for the gatekeeper to limit patient referrals to specialists.

Question 32

Medicare-eligible patients are not involved with HMOs or prepaid health plans.

Question 33

UR is the abbreviation for ____________________, which is necessary to control costs in the health care setting.

Question 34

Managed care plans allow laboratory tests to be performed at any facility the patient chooses.

Question 35

The term turfing means to transfer the sickest high-cost patients to other physicians so that the provider appears as a low utilizer.

Question 36

The process called ____________________ is an evaluation of the quality and efficiency of services rendered by a practicing physician or physicians within the specialty group.

Question 37

Usually, there are no deductibles for managed care plans.

Question 38

Exclusive provider organizations (EPOs) are regulated by the federal government.

Question 39

The Health Maintenance Organization Act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance.

Question 40

If a primary care physician sends a patient to a specialist for consultation and the specialist is not in the managed care plan, the specialist may bill the primary care physician for payment.

Question 41

A copayment in a managed care plan is usually a fixed dollar amount (predetermined fee).