Exam 3: Understanding Managed Care: Medical Contracts and Ethics

Fee schedules in managed care contracts are increasingly based on: A)Medicare's resource-based relative value scale (RBRVS) and conversion factor. B)Medicare's resource-based relative value scale (RBRVS) with a different conversion factor. C)the HMO's per-member-per-month guidelines. D)usual and customary charges adjusted by geographic area.

Emergency services are warranted if the absence of immediate medical attention could result in: A)placing the covered person's health in serious jeopardy. B)serious impairment to bodily functions. C)serious dysfunction of any bodily organ or part. D)all of the above.

In cases of fraudulent billing: A)only the physician can be held liable. B)the physician can never be held liable. C)the medical office specialist can be held liable. D)the medical office specialist can never be held liable.

Contracts between the physician and managed care organization (MCO) are generally negotiated by the: A)medical office specialist. B)physician or upper management. C)attorney. D)account manager or business manager.

In the Patient's Bill of Rights, the provision regarding choice of providers allows patients the right to: A)use any network or non-network providers. B)a network with access to appropriate high-quality healthcare. C)a network that allows second opinions from non-network providers. D)a network that includes all the physicians in a given area.

The organization that awards accreditation to managed care organizations is the: A)Centers for Medicare and Medicaid Services (CMS). B)National Center for Competency Testing (NCCT). C)National Committee for Quality Assurance (NCQA). D)World Health Organization (WHO).

The list of medical services covered under the insured's policy is called the schedule of __________ .

The schedule of benefits section of a managed care contract lists the: A)deductible and coinsurance amounts that patients must pay. B)providers in the contracted network. C)medical services covered under the managed care plan. D)benefits of participating in the managed care plan.

Managed care contracts never prohibit the provider from seeking payment directly from plan members.

In plans that require the primary care physician (PCP) to play a gatekeeper role, the PCP is given incentives to: A)expand office hours and/or staff to permit more patients to be seen each day. B)make frequent referrals to contracted network specialists. C)see as many patients each day as possible, even if this means less time with each patient. D)treat the patient as much as possible and not refer him/her to a specialist unless absolutely necessary.

Types of payment arrangements in managed care contracts include discounted fee-for-service, per diem, per case, percentage of premiums, and capitation.