Exam 3: Understanding Managed Care: Medical Contracts and Ethics

According to some contract terms, if an MCO does not pay a claim within the time limit specified in the contract, the provider may be able to: A)bill the patient directly. B)charge the usual and customary fee instead of the discounted fee. C)take legal action against the MCO. D)terminate the MCO contract after filing a written notice of intention.

With respect to a managed care contract, a medical office specialist is responsible for understanding the: A)administrative requirements of submitting claims and time frames for payment. B)process used to determine the fee schedule. C)MCO's plans for advertising and promoting the provider network. D)ownership and financial status of the MCO.

Providers are likely to agree to discounted fee-for-service contracts because they result in a(n): A)decrease in taxes paid by the physician. B)increase in the number of patients referred to the physician. C)decrease in paperwork required to file claims. D)fewer administrative tasks for the medical office assistant.

The following is true of a managed care system:

The healthcare professional in a medical practice or billing office who is responsible for submitting insurance claims may be known as a medical office specialist.

A managed care contract should clearly state all of the following EXCEPT: A)how much the physician will be paid for services. B)when payment should be received from the MCO. C)the time limit for submitting claims to the MCO. D)the list of employers with MCO contracts.

Why should a medical office specialist be familiar with terms used in managed care contracts?

In a system based on managed care, the patient's choice of provider is: A)dictated by his or her geographic location. B)dictated by his or her income. C)more limited than under a traditional fee-for-service structure. D)less limited than under a traditional fee-for-service structure.

An MCO may contract with a physician whose background is questionable in order to: A)contract with all the providers in a given area. B)make the network as large as possible. C)ensure that all specialties are available in the network. D)An MCO would never contract with a physician who has a questionable reputation.

Patients do not have the right to receive emergency services outside of their contracted network.

Under a discounted fee-for-service arrangement, covered services are compensated at a: A)discounted per-diem rate. B)per-member-per-month rate. C)reduced percentage of usual and customary charges. D)reduced per-case rate.

A managed care contract is a legal agreement between a healthcare __________ and a(n) __________ organization.

The charge a covered person is required to pay at the time covered services are provided is called a(n) __________ .

The benefits of a managed care contract to the provider include: A)keeping costs down. B)bringing more patients to the practice. C)adding opportunities for staff development. D)increasing administrative duties.

Principles adopted in the Patient's Bill of Rights include all of the following EXCEPT the right to: A)accurate and easily understood information. B)a sufficient choice of healthcare providers. C)receive emergency services without prior authorization. D)sue the managed care organization.

A policyholder in a managed care contract is also called a member or enrollee.

One aspect of healthcare reform that most people agree on is that: A)the cost of healthcare delivery is likely to decrease in the next decade. B)managed care will not be a long-term trend. C)the specific scope of necessary changes has been determined. D)reform needs to address issues of cost, access, and quality of care.

According to the Patient's Bill of Rights, the following is true regarding emergency care:

The credentialing process of a managed care organization (MCO) will examine each physician's background for evidence of all of the following except: A)criminal activity. B)disciplinary actions. C)malpractice history. D)salary history.

Provisions included in a managed care contract with a provider include: A)what is expected of the provider. B)time limits for submitting claims. C)reimbursement amounts. D)a listing of eligible patients