Question 1

The law states that an employer employing ____________________ or more persons may offer the services of an HMO clinic as an alternative health treatment plan for employees.

Accepted Answer

The answer of The law states that an employer employing...

Question 2

A significant contribution to HMO development was the

Accepted Answer

A)   CIGNA plan.
B)   Kaiser Permanente plan.
C)   Health Maintenance Organization Act of 1973.
D)   Omnibus Budget Reconciliation Act.E) A) and B)
F) None of the above C

Question 3

Kaiser Permanente's medical plan is a closed panel program, which means

Accepted Answer

A)   only certain illnesses are covered.
B)   it limits the patient's choice of personal physicians.
C)   it limits the patient's choice of a hospital for emergency care.
D)   services are provided on a fee-for-service basis.E) B) and C)
F) C) and D)

Question 4

Managed care plans never require a CMS-1500 claim form to be completed and submitted.

Accepted Answer

A) True 
 B)False

Question 5

In an independent practice association (IPA) , physicians are

Accepted Answer

A)   paid salaries by their own independent group.
B)   paid salaries by the practice association.
C)   not employees and are not paid salaries.
D)   not paid until the end of the year in which services were rendered.E) All of the above
F) A) and C)

Question 6

An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an

Accepted Answer

A)   health maintenance organization (HMO) .
B)   managed care organization (MCO) .
C)   preferred provider organization (PPO) .
D)   exclusive provider organization (EPO) .E) C) and D)
F) A) and C)

Question 7

How does an HMO receive payment for the services its physicians provide?

Accepted Answer

A)   Fee-for-service
B)   Usual, customary, and reasonable charges
C)   Allowable charges
D)   Prepaid health planE) A) and C)
F) B) and C)

Question 8

A primary care physician who controls patient access to specialists is called a/an ____________________.

Accepted Answer

The answer of A primary care physician who controls patient...

Question 9

Referral of a patient recommended by one specialist to another specialist is known as

Accepted Answer

A)   primary care.
B)   secondary care.
C)   concurrent care.
D)   tertiary care.E) None of the above
F) All of the above

Question 10

A physician-owned business that has the flexibility to deal with all forms of contract medicine and also offers its own plans is a/an

Accepted Answer

A)   IPA.
B)   PPO.
C)   PPG.
D)   POS.E) B) and D)
F) A) and D)

Question 11

Benefits under the HMO Act fall under two categories: ____________________ health services and supplemental health services.

Accepted Answer

basic

Question 12

A program that offers a combination of HMO-style cost management and PPO-style freedom of choice is a/an

Accepted Answer

A)   point-of-service (POS)  plan.
B)   exclusive provider organization (EPO) .
C)   managed care organization (MCO) .
D)   physician provider group (PPG) .E) A) and B)
F) A) and C)

Question 13

When a managed care plan requires the primary care physician to seek approval before referring a patient to a specialist, it is called obtaining ____________________.

Accepted Answer

preauthorization
prior approval

Question 14

Ross-Loos Medical Group, America's oldest privately owned prepaid medical group, started in Texas.

Accepted Answer

A) True 
 B)False

Question 15

The Health Maintenance Organization Act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance.

Accepted Answer

A) True 
 B)False

Question 16

Exclusive provider organizations (EPOs) are regulated by the federal government.

Accepted Answer

A) True 
 B)False

Question 17

The term turfing means to transfer the sickest high-cost patients to other physicians so that the provider appears as a low utilizer.

Accepted Answer

A) True 
 B)False

Question 18

Usually, there are no deductibles for managed care plans.

Accepted Answer

A) True 
 B)False

Question 19

Practitioners in an HMO program may come under peer review by a professional group called a

Accepted Answer

A)   peer review group.
B)   quality control group.
C)   Quality Improvement Organization.
D)   utilization management corporation.E) B) and C)
F) A) and B)

Question 20

In a point-of-service (POS) program, members may choose to use a nonprogram provider at any time.

Accepted Answer

A) True 
 B)False

Exam 11: The Blue Plans, Private Insurance, and Managed Care Plans

The law states that an employer employing ____________________ or more persons may offer the services of an HMO clinic as an alternative health treatment plan for employees.

Correct AnswerverifiedShow Answer

A significant contribution to HMO development was the

Correct AnswerverifiedC

Kaiser Permanente's medical plan is a closed panel program, which means

Correct AnswerverifiedShow Answer

Managed care plans never require a CMS-1500 claim form to be completed and submitted.

Correct AnswerverifiedShow Answer

In an independent practice association (IPA) , physicians are

Correct AnswerverifiedShow Answer

An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an

Correct AnswerverifiedShow Answer

How does an HMO receive payment for the services its physicians provide?

Correct AnswerverifiedShow Answer

A primary care physician who controls patient access to specialists is called a/an ____________________.

Correct AnswerverifiedShow Answer

Referral of a patient recommended by one specialist to another specialist is known as

Correct AnswerverifiedShow Answer

A physician-owned business that has the flexibility to deal with all forms of contract medicine and also offers its own plans is a/an

Correct AnswerverifiedShow Answer

Benefits under the HMO Act fall under two categories: ____________________ health services and supplemental health services.

Correct Answerverifiedbasic

A program that offers a combination of HMO-style cost management and PPO-style freedom of choice is a/an

Correct AnswerverifiedShow Answer

When a managed care plan requires the primary care physician to seek approval before referring a patient to a specialist, it is called obtaining ____________________.

Correct Answerverifiedpreauthorization prior approval

Ross-Loos Medical Group, America's oldest privately owned prepaid medical group, started in Texas.

Correct AnswerverifiedShow Answer

The Health Maintenance Organization Act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance.

Correct AnswerverifiedShow Answer

Exclusive provider organizations (EPOs) are regulated by the federal government.

Correct AnswerverifiedShow Answer

The term turfing means to transfer the sickest high-cost patients to other physicians so that the provider appears as a low utilizer.

Correct AnswerverifiedShow Answer

Usually, there are no deductibles for managed care plans.

Correct AnswerverifiedShow Answer

Practitioners in an HMO program may come under peer review by a professional group called a

Correct AnswerverifiedShow Answer

In a point-of-service (POS) program, members may choose to use a nonprogram provider at any time.

Correct AnswerverifiedShow Answer

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C

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basic

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preauthorization prior approval

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