Exam 2: Understanding Managed Care: Insurance Plans

The HMO Act of 1973 used federal funds for the purpose of: A)promoting health maintenance organizations (HMOs). B)increasing restrictions on HMOs. C)developing new managed care corporations. D)establishing a regulatory board for HMOs.

(Short Answer)

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Question 41

Which type of statement signed by the patient authorizes his or her insurance company to send payments directly to the provider? A)Assignment of benefits B)Authorization to release protected health information C)Advance directive D)Beneficiary designation

(Short Answer)

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Question 42

Disadvantages of managed care include all of the following EXCEPT: A)it includes disease management programs based on recent research. B)it creates an increased administrative burden. C)it may require physicians to carry additional malpractice insurance. D)it restricts physicians' latitude in caring for patients.

(Short Answer)

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Question 43

The restrictions in a health maintenance organization (HMO) reduce members' premium costs.

(True/False)

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Question 44

The most restrictive type of managed care plan is the: A)exclusive provider organization (EPO). B)health maintenance organization (HMO). C)individual practice association (IPA). D)preferred provider organization (PPO).

(Short Answer)

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Question 45

Match the following:

The type of managed care plan that contracts with two or more multispecialty group practices to form a provider network

individual practice association (IPA) health maintenance organization (HMO)

The type of health maintenance organization (HMO) that does not require a referral from a PCP to see a specialist

preferred provider organization (PPO)

The type of managed care plan that contracts with a multispecialty group to provide services to enrolled members

exclusive provider organization (EPO)

Correct Answer:

Verified

The type of managed care plan that contracts with two or more multispecialty group practices to form a provider network

The type of health maintenance organization (HMO) that does not require a referral from a PCP to see a specialist

The type of managed care plan that contracts with a multispecialty group to provide services to enrolled members

The type of insurance that offers protection for large medical expenses beyond the coverage of routine healthcare

The type of managed care plan that combines the features of health maintenance organization (HMO) and preferred provide organization (PPO) plans

A type of HMO in which the MCO contracts with individual physicians and facilities to build the provider network

The type of insurance that covers both medical and custodial services

The type of plan that pays benefits only for services provided by network providers but does not have a health maintenance organization (HMO) license

The type of managed care plan in which members have financial incentives, such as lower copayments, when they obtain care from network providers

The type of managed care plan that hires the physicians and pays their salaries

(Matching)

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Question 46

It is possible for a health maintenance organization (HMO) member to receive care from a non-network provider or facility in an emergency situation.

(True/False)

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Question 47

To avoid the higher costs of healthcare, employers: A)hired younger employees. B)refused to extend health insurance to employees. C)increased employee premium contributions. D)decreased the number of health plans available to employees.

(Short Answer)

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Question 48

Which of the following is a characteristic of a preferred provider organization (PPO)? A)It includes a contracted network of providers. B)Members select a primary care physician (PCP) as a gatekeeper. C)The plan is more restrictive than a health maintenance organization (HMO). D)Members must obtain referrals to see a specialist.

(Short Answer)

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Question 49

Insurance information obtained by the medical office specialist is: A)stored in the patient's medical record. B)stored separately from clinical information. C)updated on a regular basis. D)verified via phone with the insurance company.

(Short Answer)

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Question 50

Point-of-service (POS) plans require members to select a primary care physician (PCP).

(True/False)

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Question 51

A(n) __________ model health maintenance organization (HMO) contracts with more than one community-based multispecialty group to provide wider geographical coverage.

(Short Answer)

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Question 52

All health insurance contracts define medical necessity in the same way.

(True/False)

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Question 53

List four goals of managed care.

(Essay)

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Question 54

A(n) __________ medical condition is a diagnosis for which the insured has previously been treated and that may not be covered under the terms of some insurance plans.

(Short Answer)

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Question 55

A goal of managed care is for the patient to receive care in the most appropriate and most restrictive setting.

(True/False)

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Question 56

A managed care organization (MCO) collects data on care delivery, such as identifying the percentage of children in a health maintenance organization (HMO) who have been immunized.

(True/False)

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Question 57

The amount that insured individuals have to pay out of pocket before insurance begins paying is called the __________ .

(Short Answer)

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Question 58

Which of the following is true of self-insured plans?

(Multiple Choice)

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Question 59

Which of the following is true of COBRA insurance?

(Multiple Choice)

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Question 60

The HMO Act of 1973 used federal funds for the purpose of: A)promoting health maintenance organizations (HMOs). B)increasing restrictions on HMOs. C)developing new managed care corporations. D)establishing a regulatory board for HMOs.

Which type of statement signed by the patient authorizes his or her insurance company to send payments directly to the provider? A)Assignment of benefits B)Authorization to release protected health information C)Advance directive D)Beneficiary designation

The restrictions in a health maintenance organization (HMO) reduce members' premium costs.

The most restrictive type of managed care plan is the: A)exclusive provider organization (EPO). B)health maintenance organization (HMO). C)individual practice association (IPA). D)preferred provider organization (PPO).

It is possible for a health maintenance organization (HMO) member to receive care from a non-network provider or facility in an emergency situation.

To avoid the higher costs of healthcare, employers: A)hired younger employees. B)refused to extend health insurance to employees. C)increased employee premium contributions. D)decreased the number of health plans available to employees.

Insurance information obtained by the medical office specialist is: A)stored in the patient's medical record. B)stored separately from clinical information. C)updated on a regular basis. D)verified via phone with the insurance company.

Point-of-service (POS) plans require members to select a primary care physician (PCP).

A(n) __________ model health maintenance organization (HMO) contracts with more than one community-based multispecialty group to provide wider geographical coverage.

All health insurance contracts define medical necessity in the same way.

List four goals of managed care.

A(n) __________ medical condition is a diagnosis for which the insured has previously been treated and that may not be covered under the terms of some insurance plans.

A goal of managed care is for the patient to receive care in the most appropriate and most restrictive setting.

A managed care organization (MCO) collects data on care delivery, such as identifying the percentage of children in a health maintenance organization (HMO) who have been immunized.

The amount that insured individuals have to pay out of pocket before insurance begins paying is called the __________ .

Which of the following is true of self-insured plans?

Which of the following is true of COBRA insurance?

Introduction to Professional Billing and Coding Careers

Understanding Managed Care: Medical Contracts and Ethics

Hipaa: Health Insurance Portability and Accountability Act of 1996

ICD-9-CM Medical Coding

ICD-10-CM Medical Coding

Introduction to Cpt and Place of Service Coding

Coding Procedures and Services

Hcpcs and Coding Compliance

Auditing

Physician Medical Billing

Hospital Medical Billing

Medicare Medical Billing

Medicaid Medical Billing

Tricare Medical Billing

Explanation of Benefits and Payment Adjudication

Refunds and Appeals

Workers Compensation

Electronic Medical Claims Processing

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