Exam 3: Understanding Managed Care: Medical Contracts and Ethics

An increasing number of managed care plans are basing fee schedules on the Medicare __________ .

When a managed care organization (MCO) examines a physician's background for evidence of fraud or criminal activity, this is part of the process known as __________ .

The provision in the Patient's Bill of Rights that allows patients the right to review and copy their own medical records is called: A)information disclosure. B)participation in treatment decisions. C)respect and nondiscrimination. D)confidentiality of health information.

When a person has health insurance coverage through two or more plans, the determination of which plan will provide benefits as primary or secondary payer is known as: A)case management. B)benefit determination. C)coordination of benefits. D)coordination of services.

What information should be included in the schedule of benefits for a capitated plan?

Why are managed care organizations (MCOs) evaluating and grading network physicians on the services they provide?

The contract issued by a payer, the plan document, or any other legally enforceable instrument under which a covered person may be entitled to covered services is called: A)the schedule of benefits. B)the benefit plan. C)covered services. D)contracted services.

Medically necessary services include all of the following EXCEPT services that are: A)experimental, investigative, or unproven. B)based on recognized standards of the specialty involved. C)not solely for the convenience of a covered person or a healthcare provider. D)accepted by the healthcare profession as appropriate and effective for the condition being treated.

Which type of payment method creates an incentive to provide more preventive care? A)Capitation B)Per diem C)Per case D)Discounted fee-for-service

The organization that awards accreditation to health plans for meeting quality standards of healthcare delivery is the __________ .

PMPM stands for __________ .

Business values that are being incorporated in medical practices as a result of managed care include a(n): A)emphasis on the doctor-patient relationship. B)return to fee-for-service payments. C)focus on efficiency, cost reduction, and profit. D)focus on administrative requirements and paperwork.

The U.S. healthcare system can no longer accommodate unlimited demand for medical services.

If a managed care organization (MCO) pays the hospital for physician services rendered in the facility, it is the physician's responsibility to seek reimbursement from the hospital.

RBRVS stands for: A)resource-based relative value scale. B)resource-based rates of valued services. C)rates by resources and value scale. D)relative buying rates for valued services.

With MCOs, the business aspects of healthcare are not being controlled by: A)physicians. B)managers. C)accountants. D)actuaries.

Patients have the right to file a complaint about a physician or a healthcare facility in regard to waiting times or poor conduct by personnel.

A payer that is contractually obligated to make payment for medical services on behalf of the covered person can be: A)an insurance company. B)a third-party administrator. C)a self-insured health benefit plan. D)all of the above.

Explain the coordination of benefits (COB) provision in a managed care contract.

An increase in patient volume often results from: A)discounted fee-for-service contracts. B)per diem and per case contracts. C)percentage of premium and capitation contracts. D)capitation contracts.