Question 1

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 low

Question 2

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 model

Question 3

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 plans

Question 4

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 management

Question 5

PPOs differentiated themselves by offering _____ option to enrollees.

Accepted Answer

A)  point of service
B)  no out-of-pocket payment
C)  open-panel
D)  discount

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

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 enrollees

Question 8

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 9

Regional health systems are often

Accepted Answer

A)  horizontally integrated
B)  vertically integrated
C)  formed into virtual organizations
D)  formed into alliances

Question 10

A hybrid between an HMO and a PPO.

Accepted Answer

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

Question 11

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

Accepted Answer

A)  physicians
B)  insurance companies
C)  hospitals
D)  independent contractors B

Question 12

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)  Salaries

Question 13

A managed care organization functions like

Accepted Answer

A)  a provider
B)  an insurer
C)  a regulator
D)  a financier

Question 14

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

Accepted Answer

A) True 
 B)False

Question 15

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

Accepted Answer

A)  Case management
B)  Gatekeeping
C)  Utilization management
D)  Managed care

Question 16

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

Accepted Answer

A) True 
 B)False

Question 17

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 18

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 management B

Question 19

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 20

Who employs the physicians in the group practice model?

Accepted Answer

A)  The HMO
B)  The group practice
C)  The IPA
D)  The PPO

Exam 9: Managed Care and Integrated Organizations

What is the purpose of risk sharing with providers?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

Review of overutilization or underutilization is undertaken as part of

Correct AnswerverifiedShow Answer

PPOs differentiated themselves by offering _____ option to enrollees.

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedTrue

How does risk adjustment affect payments to managed care plans?

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

Regional health systems are often

Correct AnswerverifiedShow Answer

A hybrid between an HMO and a PPO.

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedB

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

Correct AnswerverifiedShow Answer

A managed care organization functions like

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

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

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

Correct AnswerverifiedB

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

Correct AnswerverifiedShow Answer

Who employs the physicians in the group practice model?

Correct AnswerverifiedShow Answer

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True

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B

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B

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