question

This is a type of cost control used by MCOs.

answer

Service management tools

question

Carve outs are:

answer

Contracts that separate out services

question

Disease management programs have had consistently positive effects.

answer

False

question

Federal legislation encouraged the growth of health maintenance organizations.

answer

True

question

Members with chronic conditions that receive appropriate assessment and therapeutic procedures in an MCO is based on:

answer

Evidence based-clinical practice guidelines

question

When specialists are reimbursed a portion of the capitated rate this is known as

answer

Subcapitation

question

All are ways that MCOs work toward their goal of quality patient care except for: Selecting providers carefully Emphasizing the health of their population Using care management tools Targeting the enrollment of healthy patients

answer

Targeting the enrollment of healthy patients

question

This rule prohibits incentives that limit medically necessary referrals.

answer

Medicare and Medicaid Programs: Requirements for Physician Incentive Plans

question

This focuses on preventing exacerbations of chronic diseases:

answer

Disease management

question

This assesses the appropriateness of the setting for healthcare services.

answer

Utilization review

question

The term to indicate prior approval for specific inpatient services is:

answer

Preadmission review

question

PPOs are the least controlled type of MCOs

answer

True

question

Medicare Part C is a form of MCO used exclusively by Medicaid beneficiaries

answer

False

question

This type of IDS is the most common.

answer

Hospital Led

question

In this type of HMO the medical group bears the risk, what type of HMO is this?

answer

Group Practice

question

Sarah goes to see a specialist out of her HMO plan. Most likely she will have to pay a higher __________________ payment.

answer

Out-of-pocket

question

Medical necessity can be defined as only those services, procedures, and patient care provided to the patient that are warranted by the patient's condition.

answer

True

question

In which type of HMO are the physicians employees?

answer

Staff Model

question

Why did Congress pass the Health Maintenance Organization Act of 1973?

answer

To encourage the delivery of affordable, quality healthcare

question

All of the following are characteristics of managed care organizations except: Coordination of care across the continuum Integration of financing and delivery of health Freedom of choice and autonomous decision making Management of costs and outcomes

answer

Freedom of choice and autonomous decision making

question

Access to mental or behavioral health or medical specialists is through referral. What is the term for the individual who makes the referral? Gatekeeper All of these answers are correct Primary care provider Primary care physician

answer

All

question

All of the following are characteristics of disease management except: Focus on single specialist for acute disease Prevention of exacerbations of chronic disease Monitoring of adherence to treatment plans Promotion of healthy life choices

answer

Focus on single specialist for acute disease

question

What is the term for an explicit statement that directs clinical decision making?

answer

Evidence-based practice guideline

question

All of the following are tools managed care organizations use to promote quality care in their healthcare plans except: Discernment in selection of providers Emphasis on health of populations Incentive to meet fiscal targets Maintenance of accreditation

answer

Incentive to meet fiscal targets

question

All of the following are purposes of the surveys that managed care organizations send their patient/members except: Perceptions of the plans' strengths and weaknesses Intentions regarding reenrollment Reasons for referral to specialists Suggestions for improvements

answer

Reasons for referral to specialists

question

The member has had gastric bypass surgery three years previously. As a result of losing over 200 pounds, loose skin hung from the member's arms, thighs, and belly. The member, upon referral from her general surgeon, was scheduled to have a plastic surgeon remove the excess skin. The member called for prior approval as required by the plan. The clinical review resulted in a denial of the surgery as cosmetic. The member requested a peer review and submitted documentation from her physician that the excess skin was causing skin infections and exacerbating her eczema. The peer clinician denied the case. What is the member's next step if she is determined to have the surgery?

answer

Appeal to an expert clinician in the same specialty

question

hat is the term that means evaluating, for a healthcare service, the appropriateness of its setting and its level of service?

answer

Utilization Review

question

Which of the following services is most likely to be considered medically necessary?

answer

Standard of care for a health condition

question

All of the following sets represent criteria for medical necessity and utilization review except: Intensity of Service, Severity of Illness, and Discharge Screens Milliman and Robertson Guidelines Federal Register Index and Ratings Appropriateness Evaluation Protocol

answer

Federal Register Index and Ratings

question

All of the following services are typically reviewed for medical necessity and utilization except: Well-baby check Inpatient admissions Mental health and chemical dependency care Rehabilitative therapies

answer

Well-baby check

question

Gatekeepers determine the appropriateness of all of the following components except: Setting in the continuum of care Level of healthcare personnel Rate of capitation or reimbursement Healthcare service itself

answer

Rate of capitation or reimbursement

question

The patient belonged to a managed care plan. Prior approval for the surgery was received. What number should the insurance analyst record?

answer

Precertification

question

The patient belonged to a managed care plan. The patient had an elective surgery. Prior approval for the elective surgery had not been obtained. What should the patient expect? Denial of reimbursement for the surgery Delay in scheduling the post-operative visit Reduction in future coverage of surgical services Increase in premium for next enrollment period

answer

Denial of reimbursement for the surgery

question

For which one of the following healthcare services is the managed care plan least likely to require a second opinion? Treatments for which experts' opinions differ on efficacy Treatment protocols that have low risk Procedures that are high cost Conditions for which the diagnostic evidence is equivocal

answer

Treatment protocols that have low risk

question

For what type of care should the physician practice manager expect to work with a case manager? Well-baby check Acute appendicitis Pre-athletics exam Workers' compensation

answer

Workers' compensation

question

What is the term for contracts that separate out certain types of healthcare services to decrease MCOs' risk ?

answer

Carve out

question

All of the following are elements of prescription management except: Formulary Patient education Alerts for interactions Links to electronic banking

answer

Links to electronic banking

question

All of the following attributes characterize episode-of-care reimbursement except: Retrospective fee-for-service Capitation Global payment Aggregation of utilization of healthy members and chronically ill members

answer

Retrospective fee-for-service

question

Phil White had coronary artery bypass graft surgery. Unfortunately, during the surgery, Phil suffered a severe stroke. Phil's recovery included several settings in the continuum of care—acute care hospital, physician office, rehabilitation center, and home health agency. This initial service and subsequent recovery lasted ten months. As a member of an MCO in an integrated delivery system, how should Phil expect that his healthcare billing will be handled?

answer

One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare providers

question

The primary care physician did not meet the MCO's target for counseling cardiac patients about smoking cessation. The primary care physician could expect any of the following results except? Reduction in salary Bonus Exemption from the surplus withholds Loss of physician contingency reserve

answer

Bonus

question

A patient, who was a Medicaid recipient, asked about the types of financial incentives that the MCO used. What should the MCO's administrator do?

answer

Release summaries of the financial incentives

question

The patient belongs to a managed care plan. The patient wants to make an appointment with an out-of-network specialist. The plan has approved the appointment as "out-of-plan." What should the patient expect?

answer

Patients out-of-pocket will increase

question

Of the following types of MCOs, which one has the strictest procedures for control of costs? Preferred provider organization Staff model Group practice model Network model

answer

Staff model

question

What is meant by the phrase "point-of-service" in "point-of-service healthcare insurance plan"?

answer

Members choose the reimbursement model (HMO, PPO, fee-for-service) when they need healthcare services rather than during the open enrollment period.

question

What is the term for an MCO that serves Medicare beneficiaries?

answer

Medicare Advantage

question

Integrated delivery systems use varying degrees of integration. Which degree of integration is least binding?

answer

Affiliation

question

In the group practice, the physicians have maintained their separate practices and offices. The individual practices share administrative systems to form a group practice. Which form of integrated delivery system does this arrangement represent?

answer

Clinic without Walls

question

Which of the following features is a benefit of consumer-directed healthcare plans? No built-in financial incentives Economies of scale based on "one size fits all" Patients' awareness of and responsibility for healthcare costs Employers can provide fewer choices

answer

Patients' awareness of and responsibility for healthcare costs

question

Today's managed care traces its origins to all of the following arrangements except: 1800, Congress awarding pensions for U.S. naval personnel on the basis of death or disability during active service 1930s, Kaiser Construction setting up health plan for its workers 1910, Western Clinic of Tacoma, Washington offering its members medical services for $0.50 per month 1929, Blue Cross of Dallas, Texas establishing schoolteachers' plan of 21 days of hospitalization for $6 per year

answer

1800, Congress awarding pensions for U.S. naval personnel on the basis of death or disability during active service

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