by schter


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An organized, interrelated system of people and facilities that communicate with one another and work together as a unit is comonly referred to as a(n): A) Network, B) Community, C) Demograph, D) Organizational Unit 
A) Network
Individuals belonging to a managed healthcare plan are referred to as: A) Beneficiaries, B) Enrollees, C) Receivers, D) Entities
B) Enrollees
The two most common types of MCOs are: A) PPOs and individual practice associations (IPAs), B) IPAs and HMOs, C) HMOs and PPOs, D) PPOs and POSs
C) HMOs and PPOs
A specific provider who oversees an HMO member's healthcare treatment is called a(n): A) Specific provider, B) Attending physician, C) Complete care provider, D) Primary care physcian (PCP)
D) Primary care physician (PCP)
The amount of money a patient has to pay out of pocket per visit is referred to as a(n): A) Copayment, B) Deductible, C) Premium, D) Allowable fee
A) Copayment
When an individual first enrolls in an HMO, he or she chooses a(n): A) Specialist, B) Insurance carrier, C) Fiscal intermediary, D) PCP
D) PCP
Most managed healthcare plans emphasize: A) Small copayments, B) Frequent physician visits, C) Preventative healthcare, D) Paying premiums on time
C) Preventative healthcare
A multispecialty group practice where all healthcare services are provided within the building(s) owned by the HMO is called a: A) Staff model, B) Group model, C) Network model, D) Direct contact model
A) Staff model
An HMO that contracts with independent, multispecialty physician groups that provide all healthcare services to its members and usually share the same facility, support staff, medical records, and equipment is called a: A) Staff model, B) Group model, C) Network model, D) Direct contact model
B) Group model
A reimbusement system in which healthcare providers receive a fixed fee for every patient enrolled in the plan, regardless of how many or few services the patient uses, is callled a(n): A) Usual, customary, and reasonable, B) Capitation, C) Misallocation, D) Allowed fee system
B) Capitation
A managed care system composed of individual healthcare providers who offer healthcare services for HMO and non-HMO patients, but maintain their own offices and identities, is called a(n): A) Network model, B) Open-panel IPA, C) Direct-contact model, D) POS plan
B) Open-panel IPA
A plan that allows patients to use the HMO provider or go outside the plan and pay a higher copayment and deductible is a(n): A) Network model, B) Open-end model, C) Direct-contact model, D) POS plan
D) POS plan
A system designed to determine the medical necessity and appropriateness of a requested medical service, procedure, or hospital admission prior, concurrent, or retrospective to the event is called: A) Accreditation, B) Certification, C) Utilization, D) Endorsement determination
C) Utilization
If a particular medical service or procedure is determined not to be "medically necessary," a patient may file a(n): A) Grievance, B) Objection, C) Lawsuit, D) Appeal
A) Grievance
A procedure required by third-party payers that requires permission before a provider can carry out specific procedures and treatments is: A) Referral, B) Certification, C) Adjudication, D) Preauthorization
D) Preauthorization
True/False
An HMO provides its members with basic healthcare services for a fixed price and for a given period of time.
TRUE
TRUE/FALSE

PPOs typically do not require authorization from a PCP for a referral to a specialist.  
TRUE
True/False

PPOs are more tightly controlled by government regulations than HMOs. 
FALSE
True/False
HMOs typically have no deductibles or plan limits.
TRUE
True/False

The Federal Government requires that HMOs operate their own facilities, staffed with salaried physicians. 
FALSE
True/False

HMOs are neither accredited nor certified.  
FALSE
Preauthorization pertains to medical necessity and appropriateness and guarantees payment.
FALSE
Precertification involved collecting information before inpatient admissions or performance of selected ambulatory procedures and services.
TRUE
A referral is a request by a healthcare provider for a patient under his or her care to be evaluated or treated or both by another provider.
TRUE
In all managed care situations, for the healthcare plan to recognize the referral, it must come from the patient's designated PCP.
FALSE
___________________________ describes types of health insurance that control the use of health services by their members so that they contain healthcare costs, the quality of care, or both.
Answer:  MANAGED CARE
An interrelated system in which people and facilities communicate with one another and work together as a unit is referred to as a(n) ______________________
NETWORK
_____________ are groups of healthcare providers who work under one umbrella to provide medical services at a discount to individuals who participate in a managed care plan.
PPO
______________ is a fixed fee per member per specified time period (usually monthly),
CAPITATION
TAF
THAT'S ALL FOLKS:)
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