Deck 3: Managed Health Care

Question 1

A managed care organization (MCO) is responsible for the health of a group of __________ and can be a health plan, hospital, physician group, or health system.

A) enrollees
B) patients
C) payers
D) providers

Answer 1

enrollees

Question 2

Which program resulted from the Balanced Budget Act of 1997 (BBA) and requires that quality assurance activities are performed to improve the functioning of Medicare Advantage (Medicare Part C) organizations?

A) peer review organization (PRO)
B) professional standard review organization (PSRO)
C) quality assessment and performance improvement (QAPI)
D) quality review organization (QIO)

Answer 2

quality assessment and performance improvement (QAPI)

Question 3

Managed health care was developed as a way to provide affordable, comprehensive, prepaid health care services to __________.

A) enrollees
B) patients
C) payers
D) providers

Answer 3

enrollees

Question 4

Many states have enacted legislation requiring a(n) __________ to review health care provided by managed care organizations.

A) external quality review organization
B) group of community members
C) subcommittee of state legislators
D) task force of out-of-state providers

Question 5

A competitive medical plan (CMP) is an HMO that meets __________ eligibility requirements for a Medicare risk contract, but is not licensed as abut is not licensed as a __________ qualified plan.

A) county; county
B) federal; federally
C) municipal; municipally
D) state; state

Question 6

The Healthcare Effectiveness Data and Information Set (HEDIS) was developed by the __________ and created standards to assess managed care systems in terms of membership, utilization of services, quality, access, health plan management and activities, and financial indicators.

A) Centers for Medicare and Medicaid Services (CMS)
B) Joint Commission
C) National Committee for Quality Assurance (NCQA)
D) Office of the Inspector General (OIG)

Question 7

The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) resulted in implementation of risk contracts, which are arrangements among providers to provide __________ health care services to Medicare beneficiaries.

A) capitated
B) fee-for-service
C) per diem
D) retrospective

Question 8

The primary care provider (PCP) is responsible for __________.

A) being a gatekeeper to provide services at the highest possible cost
B) denying all referrals to specialists and inpatient hospital admissions
C) providing nonessential health care services to all patients
D) supervising and coordinating health care services for enrollees

Question 9

The Amendment to the HMO Act of 1973 allowed federally qualified HMOs to permit members to __________.

A) always use HMO physicians and be only partially reimbursed
B) occasionally use non-HMO physicians and be partially reimbursed
C) pick a non-HMO physician and be totally reimbursed
D) switch to using non-HMO physicians and be totally reimbursed

Question 10

Managed care plans that are "federally qualified" and those that must comply with state quality review mandates, or __________, are required to establish quality assurance programs.

A) laws
B) procedures
C) regulations
D) standards

Question 11

Medicare established the Quality Improvement System for Managed Care (QISMC) to ensure the accountability of managed care plans in terms of objective, measurable __________.

A) laws
B) mandates
C) regulations
D) standards

Question 12

A quality assurance program includes activities that __________ the quality of care provided in a health care setting.

A) assess
B) deny
C) provide
D) quantify

Question 13

The Preferred Provider Health Care Act of 1985 __________ restrictions on preferred provider organizations (PPOs) and allowed subscribers to seek health care from providers outside of the PPO.

A) allowed
B) eased
C) eliminated
D) increased

Question 14

Which is a review for medical necessity of inpatient care prior to the patient's admission?

A) concurrent review
B) discharge planning
C) preadmission certification
D) preauthorization

Question 15

Which is a method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care or after care has been provided?

A) health information management
B) risk management
C) quality management
D) utilization management

Question 16

The National Committee for Quality Assurance (NCQA) reviews managed care plans and develops report cards to __________.

A) allow health care consumers to make informed decisions when selecting a plan
B) control the quality and utilization of health care services to patient populations
C) establish punitive monetary penalties that are paid by poor quality providers
D) guarantee the financial stability of managed care plans and their organizations

Question 17

With managed care's capitation financing method, if the physician provides services that cost less than the capitation amount, there is a profit, which the physician ___________.

A) distributes to all patients in the practice
B) keeps to reinvest in the medical practice
C) pays back to the managed care organization
D) reimburses to government third-party payers

Question 18

Which is a review that grants prior approval for reimbursement of a health care service?

A) concurrent review
B) discharge planning
C) preadmission certification
D) preauthorization

Question 19

The Health Maintenance Organization (HMO) Assistance Act of 1973 authorized grants and loans to develop HMOs under private sponsorship. It defines a federally qualified HMO as being certified to provide health care services to __________ enrollees.

A) anyone with U.S. citizenship as
B) commercial and government
C) Medicare and Medicaid
D) TRICARE and CHAMPVA

Question 20

Reviewing the appropriateness and necessity of care provided to patients prior to the administration of care is called __________ review, and such review after care has been provided is called __________ review.

A) prospective; retrospective
B) retrospective; prospective

Question 21

Prior to scheduling elective surgery, managed care plans often require a __________ during which another physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery.

A) preauthorization
B) prospective review
C) retrospective review
D) second surgical opinion

Question 22

Which involves the development of patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner?

A) case management
B) risk management
C) quality management
D) utilization management

Question 23

Which is associated with contracted health care services that are delivered to subscribers by individual physicians in the community?

A) direct contract model HMO
B) group model HMO
C) network model HMO
D) staff model HMO

Question 24

An integrated delivery system (IDS) is an organization of __________ that offer joint health care services to subscribers.

A) affiliated providers' sites
B) government agencies
C) nonparticipating providers
D) third-party payers

Question 25

Which is a review for medical necessity of tests and procedures ordered during an inpatient hospitalization?

A) concurrent review
B) discharge planning
C) preadmission certification
D) preauthorization

Question 26

Some managed care plans contract out utilization management services to a utilization review organization (URO), which is an entity that __________.

A) conducts a quality management program and completes focused review studies and medical audits
B) establishes a utilization management program and performs external utilization review services
C) performs risk management activities that result in appropriate in-service education for medical staff
D) provides a service to the organization to ensure that physicians have met credentialing requirements

Question 27

Which involves arranging appropriate health care services for the patient who is being released from an inpatient hospitalization?

A) concurrent review
B) discharge planning
C) preadmission certification
D) preauthorization

Question 28

Which is associated with health care that is provided in an HMO-owned center or satellite clinic or by physicians who belong to a specially formed medical group that serves the HMO?

A) closed-panel HMO
B) open-panel HMO

Question 29

Health care services provided to subscribers by physicians employed by the HMO are associated with a __________. Premiums and other revenue are paid to the HMO, and usually all ambulatory services are provided within HMO corporate buildings.

A) direct contract model HMO
B) group model HMO
C) network model HMO
D) staff model HMO

Question 30

A management service organization (MSO) is usually owned by physicians or a hospital and provides practice management (administrative and support) services to __________.

A) government health programs
B) individual physician practices
C) managed care organizations
D) third-party payers

Question 31

A physician-hospital organization (PHO) is owned by hospital(s) and physician groups that obtain managed care plan contracts. The physicians __________ and provide health care services to plan members.

A) are employed by the PHO
B) calculate what they want to earn
C) maintain their own practices
D) purchase the PHO building

Question 32

Which is associated with health care that is provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO?

A) closed-panel HMO
B) open-panel HMO

Question 33

A health maintenance organization (HMO) is an alternative to traditional group health insurance coverage and provides comprehensive health care services to voluntarily enrolled members on a __________ basis.

A) fee-for-service
B) per diem
C) prepaid
D) retrospective

Question 34

A group practice without walls (GPWW) establishes a contract that allows physicians to maintain their own offices and share services, such as __________.

A) admitting patients to the hospital
B) appointment scheduling and billing
C) performing surgical procedures
D) providing office services to patients

Question 35

An integrated provider organization (IPO) manages the delivery of health care services offered by hospitals, physicians, and other health care organizations. Physicians associated with an IPO are considered __________.

A) employees
B) independent contractors
C) self-employed
D) temporary staff

Question 36

Which is associated with contracted health care services that are provided to subscribers by two or more physician multispecialty group practices?

A) direct contract model HMO
B) group model HMO
C) network model HMO
D) staff model HMO

Question 37

Physician incentives include payments made directly or indirectly to health care providers to __________ so as to save money for the managed care plan. Managed care plans that contract with Medicare or Medicaid must disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval.

A) contractually provide limits and quotas for services
B) encourage them to reduce or limit patient services
C) prevent physicians from receiving payment for services
D) underwrite exotic travel and other bonuses for services

Question 38

Which is associated with contracted health care services that are delivered to subscribers by participating physicians who are members of an independent multispecialty group practice?

A) direct contract model HMO
B) group model HMO
C) network model HMO
D) staff model HMO

Question 39

Medicare and many states prohibit managed care contracts from containing __________, which prevent providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.

A) credentialing statements
B) gag clauses
C) physician incentives
D) profit margins

Question 40

A medical foundation is a nonprofit organization that contracts with and __________ the clinical and business assets of physician practices.

A) acquires
B) indentures
C) leases
D) liquidates

Question 41

Triple option plans are intended to prevent the problem of covering members who are sicker than the general population, which is called __________ selection.

A) adverse
B) indeterminate
C) risk
D) pool

Question 42

Which is a voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law?

A) accreditation
B) mandate
C) regulation
D) requirement

Question 43

A managed care network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee is called a(n) __________.

A) independent practice association
B) point-of-service plan
C) preferred provider organization
D) triple option plan

Question 44

Which type of HMO contracts health services that are delivered to subscribers by physicians who remain in their own office settings?

A) independent practice association
B) point-of-service plan
C) preferred provider organization
D) triple-option plan

Question 45

Which consumer-directed health plan allows tax-exempt accounts to be offered by employers with 50 or more employees, which individuals then use to pay health care bills? Funds must be used for qualified health care expenses, and unspent money can be accumulated for future years. If an employee changes jobs, he or she can continue to use the funds to pay for qualified health care expenses.

A) customized sub-capitation plan
B) flexible spending account
C) health savings account
D) health reimbursement arrangement

Question 46

Which is a private, not-for-profit organization that assesses the quality of managed care plans in the United States and releases the data to the public for consideration when selecting a managed care plan?

A) Centers for Medicare and Medicaid Services
B) department of health in each state
C) National Committee for Quality Assurance
D) The Joint Commission

Question 47

Which is usually offered either by a single insurance plan or as a joint venture among two or more insurance payers and provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans?

A) independent practice association
B) point-of-service plan
C) preferred provider organization
D) triple option plan

Question 48

A triple option plan is also called a __________ or flexible benefit plan because of the different benefit plans and extra coverage options provided through the insurer or third-party administrator.

A) cafeteria plan
B) optional contract
C) rider
D) underwriter

Question 49

Which consumer-directed health plan allows participants to enroll in a relatively inexpensive high-deductible insurance plan and open a tax-deductible savings account to cover current and future medical expenses? Money deposited (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax-free. Money can be withdrawn for purposes other than health care expenses after payment of income tax plus a 15 percent penalty. Unused balances "roll over" from year to year, and if an employee changes jobs, he or she can continue to use the fund to pay for qualified health care expenses.

A) customized sub-capitation plan
B) flexible spending account
C) health savings account
D) health reimbursement arrangement

Question 50

Which consumer-directed health plan funds health care expenses with insurance coverage and the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium?

A) customized sub-capitation plan
B) flexible spending account
C) health savings account
D) health reimbursement arrangement

Question 51

Which consumer-directed health plan provides tax-exempt accounts offered by employers to any number of employees, which individuals use to pay health care bills? The employees contribute funds through a salary reduction agreement and withdraw funds to pay medical bills. Funds are exempt from both income tax and Social Security tax (and employers may also contribute). By law, employees forfeit unspent funds at the end of the year.

A) customized sub-capitation plan
B) flexible spending account
C) health savings account
D) health reimbursement arrangement

Question 52

Which is created when a number of people are grouped for insurance purposes and the cost of health care coverage is determined by employees' health status, age, sex, and occupation?

A) cafeteria plan
B) managed care
C) risk pool
D) self-referral

Question 53

To create flexibility in managed care plans, some HMOs and preferred provider organizations have implemented a(n) __________, under which patients have freedom to use the managed care panel of providers or to self-refer to out-of-network providers.

A) independent practice association
B) point-of-service plan
C) preferred provider organization
D) triple option plan

Question 54

Accreditation organizations develop standards that are reviewed during an evaluation process that is conducted both offsite and onsite. The evaluation process is called a(n) __________.

A) audit
B) inspection
C) review
D) survey