Exam 1

Front 1

True or false? PPOs differ from HMOs because they do not accept capitation risk and enrollees who are willing to pay higher cost sharing may access providers that are not in the contracted network.

Back 1

A. True

Front 2

True or false? Health care cost inflation has remained consistent since 1995.

Back 2

B. False

Front 3

True or false? HMOs are licensed as health insurance companies.

Back 3

B. False

Front 4

True or false? Hospitals purchased physician practices and employed physicians in the 1990s, but will no longer do so.

Back 4

B. False

Front 5

True or false? The HIPDB is a national health care fraud and abuse data collection program for the reporting and disclosure of certain final adverse actions taken against health care providers, suppliers, or practitioners.

Back 5

A. True

Front 6

True or false? Physicians avoid working for hospitals as much as possible.

Back 6

B. False

Front 7

rue or false? The same methodology used to pay a hospital for inpatient care is usually also use to pay for outpatient care.

Back 7

B. False

Front 8

True or false? Fee-for-service payment is the most common method used by HMOs to pay specialists.

Back 8

A. True

Front 9

True or false? The use of utilization guidelines targets only managed care patients and does not have an impact on the care of non-managed care patients.

Back 9

B. False

Front 10

True or false? Nurse-on-call or medical advice programs are considered demand management strategies.

Back 10

A. True

Front 11

True or false? UM focuses on telling doctors and hospitals what to do.

Back 11

B. False

Front 12

True or false? Hospital utilization varies by geographical area.

Back 12

A. True

Front 13

True or false? Nonphysician practitioners deliver most of the care in disease management systems.

Back 13

A. True

Front 14

True or false? Fee-for-service physicians are financially rewarded for good disease management in most environments.

Back 14

B. False

Front 15

True or false? Outbound calls to physicians are an important aspect to most DM programs.

Back 15

B. False

Front 16

True or false? The typical practicing physician has a good understanding of what is happening with his or her patient between office visits.

Back 16

B. False

Front 17

True or false? Primary prevention in health care is the early detection of disease.

Back 17

B. False

Front 18

True or false? From a societal standpoint, the health and financial benefits of preventing disease are compelling.

Back 18

A. True

Front 19

True or false? Of all preventive services with evidence of effectiveness, the three with the greatest potential for impacting health and health care costs are: a) aspirin use in high-risk adults, b) childhood immunization series, and c) tobacco use screening and brief intervention.

Back 19

A. True

Front 20

True or false? Physicians are the backbone of a plan's provider network.

Back 20

A. True

Front 21

True or false? Capitation is easier for a health plan to administer than fee for service.

Back 21

A. True

Front 22

True or false? Prepayment for service began when he HMO Act was passed.

Back 22

B. False

Front 23

True or false? Managed Care started in the West because there were not enough hospitals.

Back 23

B. False

Front 24

True or false? All reimbursement models end up being a variation of fee for service or capitation.

Back 24

A. True

Front 25

True or false? Hospitals are not that important to have in a provider network because the goal is to keep members out of the hospital.

Back 25

B. False

Front 26

Prior to the 1970s, health maintenance organizations (HMOs) were known as:

Back 26

C. Prepaid group practices.

Front 27

The original impetus of HMOs development came from:

Back 27

D. All of the above. (A. Providers seeking patient revenues. B. Consumers seeking access to health care. C. Employers.)

Front 28

The integral components of managed care are:

Back 28

E. All of the above.(A. Wellness and prevention. B. Primary care orientation. C. Utilization management. D. A and C only.)

Front 29

Managed care is best described as:

Back 29

B. A broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage cost, quality, and access to that care.

Front 30

Key common characteristics of PPOs include:

Back 30

E. All of the above. (A. Selected provider panels. B. Negotiated payment rates. C. Consumer choice. D. Utilization management.)

Front 31

Commonly recognized HMOs include:

Back 31

F. A, B and D only. (A. IPAs. B. Network. D. Staff and group.)

Front 32

Capitation is usually defined as:

Back 32

A. Prepayment for services on a fixed, per member per month basis.

Front 33

In what model does an HMO contract with more than one group practice provide medical services to its members?

Back 33

A. Group model.

Front 34

Who has final responsibility for all aspects of an independent HMO?

Back 34

D. Board of Directors.

Front 35

Medical Directors typically have responsibility for:

Back 35

E. All of the above.(A. Utilization management. B. Benefits determinations for appeals. C. Quality management. D. A and C only.)

Front 36

When selecting a hospital during the network development phase, an HMO considers:

Back 36

E. A and C only.(A. Occupancy rate.C. Scope of services.)

Front 37

Ancillary services are broadly divided into the following categories:

Back 37

C. Diagnostic and therapeutic.

Front 38

State and federal regulations consistently apply network access standards to:

Back 38

A and B only.(A. HMOs. B. POS plans)

Front 39

The following term refers to an all-inclusive rate paid by the HMO for both institutional and professional services:

Back 39

D. Bundled payment.

Front 40

Which of the following forms of hospital payment contain no elements of risk sharing by the hospital?

Back 40

D. Sliding scale FFS.

Front 41

What are the basic ways to compensate open-panel PCPs?

Back 41

D. A and C only. (A. Capitation. C. Fee-for-service.)

Front 42

Capitation is a physician payment method preferred by many HMOs because it:

Back 42

E. All of the above.(A. Eliminates the FFS incentive to over utilize B. Costs are predictable. C. Is less costly to administer than FFS. D. A and C only.)

Front 43

Payment to a facility for outpatient procedures may be increased on a case-by-case basis through which of the following?

Back 43

B. Carve-outs.

Front 44

Utilization management seeks to reduce practice variation while promoting good outcomes and ___.

Back 44

D. None of the above.(A. Reducing access. B. Maintaining costs. C. Increasing patients.)

Front 45

The most common measurement of inpatient utilization is:

Back 45

D. Bed days per thousand enrollees.

Front 46

Claims review is an example of:

Back 46

C. Retrospective review.

Front 47

The least appropriate site for disease management is:

Back 47

B. Inpatient setting.

Front 48

Establishing a high level of evidence regarding disease management guidelines ensures:

Back 48

B. Validity.

Front 49

Which of the following are components of a strong MCO prevention program?

Back 49

F. A, B, C and D.(A. Member benefits. B. Services for members, such as health risk assessments. C. Contracts with providers. D. Public policies.)

Front 50

Managed care organizations can use which of the following contracting strategies to influence physicians and encourage their delivery of effective preventive services?

Back 50

D. All of the above. (A. Pay for performance based on documented improvements in patient outcomes. B. Feedback to physicians and provider groups on their performance relative to peers. C. Reminders to providers about specific patients' needs for services.)