Question 1

PPOs were created by ____ in response to HMOs' growing market share.

Accepted Answer

A)  physicians
B)  insurance companies
C)  hospitals
D)  independent contractorsE) C) and D)
F) All of the above B

Question 2

Review of overutilization or underutilization is undertaken as part of

Accepted Answer

A)  concurrent utilization review
B)  retrospective utilization review
C)  prospective utilization review
D)  case managementE) A) and B)
F) A) and C)

Question 3

One goal of ______ in pharmaceutical management is to change physicians' future prescribing habits if necessary.

Accepted Answer

A)  concurrent utilization review
B)  retrospective utilization review
C)  prospective utilization review
D)  case managementE) C) and D)
F) All of the above B

Question 4

What is the purpose of risk sharing with providers?

Accepted Answer

A)  It makes providers immune to costs
B)  It makes providers cost conscious
C)  It rewards providers for quality
D)  It keeps insurance premiums lowE) A) and C)
F) C) and D)

Question 5

Under a payment arrangement in which physicians are paid a fixed salary and performance-based bonuses, risk is shifted from the MCO to the physicians.

Accepted Answer

A) True 
 B)False

Question 6

The majority of Medicaid beneficiaries and enrollees in Medicare Advantage plans receive health care services through HMOs.

Accepted Answer

A) True 
 B)False  True

Question 7

Which type of MCO has achieved the greatest success in employment-based enrollment?

Accepted Answer

A)  HMOs
B)  PPOs
C)  POS plans
D)  Exclusive provider plansE) All of the above
F) A) and C)

Question 8

PPOs differentiated themselves by offering _____ option to enrollees.

Accepted Answer

A)  point of service
B)  no out-of-pocket payment
C)  open-panel
D)  discountE) A) and C)
F) All of the above

Question 9

Cost-effective management of care for patients who have complex medical conditions.

Accepted Answer

A)  Case management
B)  Gatekeeping
C)  Utilization management
D)  Managed careE) A) and C)
F) A) and D)

Question 10

How does risk adjustment affect payments to managed care plans?

Accepted Answer

A)  Risk adjustment shifts risk from the payer to the MCO
B)  Risk adjustment takes into account the enrollees' health status
C)  Risk adjustment provides an incentive for improving quality
D)  Risk adjustment reduces out-of-pocket costs for the enrolleesE) A) and B)
F) C) and D)

Question 11

A managed care organization functions like

Accepted Answer

A)  a provider
B)  an insurer
C)  a regulator
D)  a financierE) C) and D)
F) B) and C)

Question 12

In which HMO model is the choice of physicians likely to be most restricted?

Accepted Answer

A)  Staff model
B)  Group model
C)  Network model
D)  IPA modelE) None of the above
F) C) and D)

Question 13

In the 1990s, managed care was widely credited for enabling small employers to offer health insurance coverage to their employees.

Accepted Answer

A) True 
 B)False

Question 14

A hybrid between an HMO and a PPO.

Accepted Answer

A)  Point-of-service plans
B)  Mixed model HMO
C)  IPA
D)  Exclusive provider plansE) A) and D)
F) A) and C)

Question 15

Regional health systems are often

Accepted Answer

A)  horizontally integrated
B)  vertically integrated
C)  formed into virtual organizations
D)  formed into alliancesE) B) and D)
F) B) and C)

Question 16

What payment method is used in Primary Care Case Management to reimburse physicians?

Accepted Answer

A)  Capitation
B)  Discounted fees
C)  Fee for service
D)  SalariesE) A) and D)
F) All of the above

Question 17

Who employs the physicians in the group practice model?

Accepted Answer

A)  The HMO
B)  The group practice
C)  The IPA
D)  The PPOE) A) and B)
F) A) and C)

Question 18

By prescribing minimum medical loss ratios in health plans, the ACA will limit the percentage of premium revenue a health plan can use for administration, marketing, and profits.

Accepted Answer

A) True 
 B)False

Question 19

All MCOs are now required to be accredited by the National Committee for Quality Assurance.

Accepted Answer

A) True 
 B)False

Question 20

Research shows that quality of care has declined as managed care has continued to grow.

Accepted Answer

A) True 
 B)False

Exam 9: Managed Care and Integrated Organizations

PPOs were created by ____ in response to HMOs' growing market share.

Correct AnswerverifiedB

Review of overutilization or underutilization is undertaken as part of

Correct AnswerverifiedShow Answer

One goal of ______ in pharmaceutical management is to change physicians' future prescribing habits if necessary.

Correct AnswerverifiedB

What is the purpose of risk sharing with providers?

Correct AnswerverifiedShow Answer

Under a payment arrangement in which physicians are paid a fixed salary and performance-based bonuses, risk is shifted from the MCO to the physicians.

Correct AnswerverifiedShow Answer

The majority of Medicaid beneficiaries and enrollees in Medicare Advantage plans receive health care services through HMOs.

Correct AnswerverifiedTrue

Which type of MCO has achieved the greatest success in employment-based enrollment?

Correct AnswerverifiedShow Answer

PPOs differentiated themselves by offering _____ option to enrollees.

Correct AnswerverifiedShow Answer

Cost-effective management of care for patients who have complex medical conditions.

Correct AnswerverifiedShow Answer

How does risk adjustment affect payments to managed care plans?

Correct AnswerverifiedShow Answer

A managed care organization functions like

Correct AnswerverifiedShow Answer

In which HMO model is the choice of physicians likely to be most restricted?

Correct AnswerverifiedShow Answer

In the 1990s, managed care was widely credited for enabling small employers to offer health insurance coverage to their employees.

Correct AnswerverifiedShow Answer

A hybrid between an HMO and a PPO.

Correct AnswerverifiedShow Answer

Regional health systems are often

Correct AnswerverifiedShow Answer

What payment method is used in Primary Care Case Management to reimburse physicians?

Correct AnswerverifiedShow Answer

Who employs the physicians in the group practice model?

Correct AnswerverifiedShow Answer

By prescribing minimum medical loss ratios in health plans, the ACA will limit the percentage of premium revenue a health plan can use for administration, marketing, and profits.

Correct AnswerverifiedShow Answer

All MCOs are now required to be accredited by the National Committee for Quality Assurance.

Correct AnswerverifiedShow Answer

Research shows that quality of care has declined as managed care has continued to grow.

Correct AnswerverifiedShow Answer

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