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Exam 3: Managed Health Care

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Question 1

Multiple Choice

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Managed care plans that are "federally qualified" and those that must comply with state quality review mandates, or __________, are required to establish quality assurance programs.

A) laws
B) procedures
C) regulations
D) standards

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Question 2

Multiple Choice

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A managed care organization (MCO) is responsible for the health of a group of __________ and can be a health plan, hospital, physician group, or health system.

A) enrollees
B) patients
C) payers
D) providers

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Question 3

Multiple Choice

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Which is associated with health care that is provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO?

A physician-hospital organization (PHO) is owned by hospital(s) and physician groups that obtain managed care plan contracts. The physicians __________ and provide health care services to plan members.

Which is a voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law?

An integrated provider organization (IPO) manages the delivery of health care services offered by hospitals, physicians, and other health care organizations. Physicians associated with an IPO are considered __________.

Which program resulted from the Balanced Budget Act of 1997 (BBA) and requires that quality assurance activities are performed to improve the functioning of Medicare Advantage (Medicare Part C) organizations?

Which consumer-directed health plan funds health care expenses with insurance coverage and the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium?

Which is a review for medical necessity of tests and procedures ordered during an inpatient hospitalization?

Which is associated with contracted health care services that are provided to subscribers by two or more physician multispecialty group practices?

Which is associated with contracted health care services that are delivered to subscribers by participating physicians who are members of an independent multispecialty group practice?

Many states have enacted legislation requiring a(n) __________ to review health care provided by managed care organizations.

Medicare established the Quality Improvement System for Managed Care (QISMC) to ensure the accountability of managed care plans in terms of objective, measurable __________.

The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) resulted in implementation of risk contracts, which are arrangements among providers to provide __________ health care services to Medicare beneficiaries.

With managed care's capitation financing method, if the physician provides services that cost less than the capitation amount, there is a profit, which the physician ___________.

A managed care network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee is called a(n) __________.

A health maintenance organization (HMO) is an alternative to traditional group health insurance coverage and provides comprehensive health care services to voluntarily enrolled members on a __________ basis.

A quality assurance program includes activities that __________ the quality of care provided in a health care setting.

Which is a review that grants prior approval for reimbursement of a health care service?

The primary care provider (PCP) is responsible for __________.