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Exam 3: Managed Health Care

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Question 21

Multiple Choice

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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

E) All of the above
F) A) and C)

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Question 22

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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)

E) None of the above
F) A) and C)

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Question 23

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

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.

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?

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.

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?

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.

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.

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

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 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.

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

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

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.

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.

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.

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?

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