1.

COMPARATIVE HEALTH INFORMATION

MANAGEMENT 4TH EDITION PEDEN

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Chapter 04 Managed Care

MULTICHOICE

1. Medicare Advantage (formerly Medicare + Choice) is _.

(A) a Medicare managed care program

(B) the use of supplemental insurance to pay for medical expenses not covered under Medicare

(C) a program for physicians that allows them to choose to participate in Medicare or not

(D) a federal health care program created by the Patient Protection and Affordable Care Act (PPACA)
to replace and expand traditional Medicare

Answer : (A)

2. A core set of standard performance measures for managed care in the areas of quality, access and
patient satisfaction, membership, utilization, finance, and health plan management is named
.

(A) MCO
(B) ISDN (C)

HEDIS (D)

SPM-MC

Answer : (C)

3. Verifying medical necessity of tests and procedures ordered during an inpatient hospitalization is
called .

(A) concurrent review

(B) coinsurance

(C) gatekeeping

(D) credentialing

Answer : (A)

4. Determining which insurance is the primary payer and assuring that no more than 100 percent of
the charges are paid to the provider and/or reimbursed to the patient is called .

(A) capitation

(B) coinsurance
(C) gatekeeping

(D) coordination of benefits

Answer : (D)

5. The amount of medical expenses that insureds must pay each year from their own pockets before
the plan will reimburse them is called the .

(A) coinsurance

(B) deductible

(C) copayment

(D) per annum

Answer : (B)

6. One aspect of Medicare managed care is that .

(A) premiums to HMOs are risk-adjusted based on patient diagnoses

(B) Medicare pays physicians directly through fee-for-service arrangements

(C) additional premiums are paid to all HMOs who employ certified wellness coordinators

(D) hospitals with Joint Commission accreditation are not deemed to meet the Conditions of
Participation for Managed Care

Answer : (A)

7. The managed care primary care provider (PCP) who coordinates all patient health care needs and
decides what, if any, additional care or testing is required is acting as a(n) .

(A) coinsurer

(B) network

(C) gatekeeper

(D) indemnifier

Answer : (C)

8. Individuals who are the primary recipients of the managed care insurance benefit within a
managed care organization are referred to as _.

(A) patients
(B) dependents

(C) subscribers

(D) beneficiaries

Answer : (C)

9. The spouse or child of the primary recipient of the managed care insurance benefit within a
managed care organization is referred to as a .

(A) contract (B)

dependent (C)

subscriber (D)

beneficiary

Answer : (B)

10. Mid-level providers are often used in managed care to provide illness-related services to
patients; they include .

(A) physicians

(B) case managers (C)

health educators (D)

nurse practitioners

Answer : (D)

11. A managed care organization (MCO) that undergoes evaluation of its ability to perform as an
insurance provider will request accreditation from .

(A) CMS

(B) NCQA

(C) AAAHC

(D) The Joint Commission

Answer : (B)

12. The authorization to receive a specific health service from a specific health provider is called
a(n) .
(A) transfer

(B) referral

(C) encounter

(D) remittance

Answer : (B)

13. The determination as to whether a person is allowed to receive care under a managed care
organization contract is called .

(A) eligibility

(B) enrollment

(C) entitlement

(D) case management

Answer : (A)

14. The process of review to approve a provider, such as a physician, who applies to participate in a
health plan is .

(A) evaluation

(B) regulation

(C) credentialing

(D) accreditation

Answer : (C)

15. Ensuring that a provider is not underutilizing services and compromising the health of
managed care members or overutilizing services and creating unnecessary expense is
.

(A) service regulation

(B) financial supervision

(C) enrollment managemen

(D) economic credentialing

Answer : (D)
16. The 20 percent expense that is the responsibility of the insured under an indemnity insurance
policy is called .

(A) coinsurance

(B) copayment

(C) self-indemnity

(D) point-of-service fee

Answer : (A)

SHORTANSWER

17. A is a mechanism by which an employer funds an

account for its employees to pay for otherwise unreimbursed health care expenses.Answer : Health
Reimbursement Arrangement (HRA)

TRUEFALSE

18. All individuals eligible to receive care within the managed care organization (MCO) are referred
to as residents.

(A) True (B)

False

Answer : (B)

19. Medicare managed care plans receive payments under the Medicare Advantage program for
enrollees who have both Part A and Part B coverage.

(A) True (B)

False

Answer : (A)

20. Preventive care and wellness are a central focus of a health maintenance organization and most
managed care organizations.

(A) True (B)

False

Answer : (A)
21. In the staff model HMO, the HMO entity owns the facilities and arranges for health care through
employed physicians, who are allowed to see only the particular HMO's patients.

(A) True (B)

False

Answer : (A)

22. The Clinical Laboratory Improvement Amendments (CLIA) require that every laboratory possess
a certificate to operate and that laboratories that fail to meet the operational standards or
proficiency testing guidelines be sanctioned.

(A) True (B)

False

Answer : (A)

23. Coordination of benefits (COB) allows excess reimbursement from health plans to providers to
be refunded to the patient.

(A) True (B)

False

Answer : (B)

24. A managed care organization that meets TJC or AAAHC standards is deemed to meet NCQA
standards.

(A) True

(B) False

Answer : (B)

25. The managed care organization (MCO) produces its revenue by selling an insurance product and
must reimburse providers for services delivered to members.

(A) True (B)

False

Answer : (A)

26. A provider's panel is the group of patients who have chosen the provider as their primary care
provider (PCP).
(A) True (B)

False

Answer : (A)

27. Capitation is the payment of a fixed dollar amount for each covered person for the provision of a
predetermined set of health care services for a specific period of time.

(A) True (B)

False

Answer : (A)

28. The MCO negotiates per diem rates with individual physicians.

(A) True

(B) False

Answer : (B)

29. A fee schedule is a predetermined rate for each procedure, visit, or service. Negotiating a fee
schedule allows more consistent budgeting of payment dollars by the managed care organization.

(A) True (B)

False

Answer : (A)

30. The resource-based relative value scale (RBRVS) system is an example of per diem
reimbursement.

(A) True (B)

False

Answer : (B)

31. When a provider agrees to see managed care organization (MCO) patients and to subtract a
certain percentage from the regular fee-for-service rate, this is called discounted charges.

(A) True (B)

False

Answer : (A)
32. An employee who is injured on the job must receive care from a provider selected by the
workers' compensation carrier.

(A) True (B)

False

Answer : (B)

33. Per diem means "paid by the day or at a daily rate."

(A) True

(B) False

Answer : (A)

34. An MCO is built on contracted relationships. An index of contracts, including expira-tion dates
and any proposed contract changes, is maintained to be sure all contracts remain valid and at an
optimal level of reimbursement.

(A) True (B)

False

Answer : (A)

SHORTANSWER

35. A(n) is a Medicare pilot payment program in which an organization

composed of a local entity and a related set of providers can be held responsible for the cost and
quality of care through financial rewards for good performance based on comprehensive quality and
spending measurement and monitoring.Answer : Accountable Care Organization

36. are disease groupings based on ICD codes from both inpatient
admissions and outpatient visits that are used to risk-adjust Medicare payments to Medicare
Advantage MCOs.Answer : Hierarchical Condition Categories
Answer : HCCs

MATCH

37. Match each item with the correct description below.

MATCH

38. Match each item with the correct description below.

MATCH

39. Match each item with the correct description below.

ESSAY

40. Describe the following activities that are completed through utilization management:
preadmission certification, preauthorization, concurrent review and discharge planning.

Graders Info :

● Preadmission certification: involves reviewing the necessity of an admission prior to its occurrence
Discharge planning: arranging services that patients may require upon discharge
● Preauthorization: a review of elective procedures requiring prior approval for re-imbursement
● Concurrent review: reviewing services ordered for medical necessity during an inpatient
hospitalization before they are provided

41. Describe three criteria involved with credentialing.

Graders Info :

Any three of the following:

● Current competence in the field
● Work history
● Physical and mental health status
● Challenges to licensure and registrations
● Limitation or termination of clinical privileges
● Pending professional liability actions
● Felony convictions
● Federal Drug Enforcement Administration registration
● National Practitioner Data Bank information

42. Describe what a POS plan is and how it helps plan members with the ability to choose their
services.

Graders Info :

A point-of-service plan (POS) is a hybrid of the HMO and PPO models. An individual enrolled in the
PPO plan pays a premium and his or her care is managed by a primary care provider, similarly to an
HMO. However, unlike an HMO the member can still obtain care from a provider outside of the
preferred network. The coverage for services rendered by an out-of-network provider is reimbursed
at a lesser rate in keeping with the PPO model. The remaining charges and increased copays
resulting from receiving services from a provider outside of the preferred group are the
responsibility of the insured. By enrolling in a point-of-service plan, members choose the type of
provider to use and how much out-of-pocket expense they are willing to pay in return for that ability
to choose.

43. Give examples of various types of voluntary accreditation an MCO could choose.

Graders Info :

MCO could decide on any of these approaches:

● National Committee for Quality Assurance (NCQA) accreditation
● The Joint Commission (TJC) accreditation or Accreditation Association for Ambulatory Health Care
(AAAHC) accreditation
● Both NCQA and TJC or AAAHC accreditation

44. Describe what an accountable care organization (ACO) is.

Graders Info :

ACOs can generally be defined as a local entity and a related set of providers, including at least
primary care physicians, specialists, and hospitals, that can be held accountable for the cost and
quality of care delivered to a defined subset of traditional Medicare program beneficiaries or other
defined populations, such as commercial health plan subscribers. The primary ways the entity would
be held accountable for its performance are through changes in traditional Medicare provider
payment featuring financial rewards for good performance based on comprehensive quality and
spending measurement and monitoring. Public reporting of cost and quality information to affect
public perception of an ACO's worth is an-other way of holding the ACO accountable for its
performance. Proponents generally view three ACO characteristics as essential. These
characteristics include: (1) the ability to provide, and manage with patients, the continuum of care
across different institutional settings, including at least ambulatory and inpatient hospital care and
possibly post-acute care; (2) the capability of prospectively planning budgets and resource needs;
and, (3) sufficient size to support comprehensive, valid, and reliable performance measurement".