Chapter 2

Question 1

Allows coordination among providers, monitoring of quality, and identification of superior or cost-efficient providers as well as inappropriate use.

Answer 1

utilization review

Question 2

Organized healthcare systems responsible for both financing and arranging the delivery of a broad range of health services to a defined population.

Answer 2

health maintenance organizations (HMO)

Question 3

Entities through which employer benefit plans and health insurance carriers contract to purchase healthcare services for beneficiaries from a selected group of participating providers.

Answer 3

preferred provider organization (PPO)

Question 4

A legal entity of independent physicians who contract with the IPA with the sole purpose of having the IPA contract with HMOs.

Answer 4

independent practice association (IPA)

Question 5

Organization of physicians who are not dependent on a hospital for services or support. Owned and governed by physicians. Practice aggregated into a legal entity, but still have independent locations.

Answer 5

group practice without walls (GPWW)

Question 6

True group practice. Combined assets and risks but physicians remain in their own offices.

Answer 6

consolidated medical group (CMG)

Question 7

Business entity that allows a hospital and it’s physicians to negotiate with third-party payers.

Answer 7

physician/hospital organizations (PHO)

Question 8

Tax-exempt organizations (i.e. hospital) creates a non-profit foundation that purchases and operates physicians’ practices.

Answer 8

foundation model integrated delivery system

i.e. St. Mary’s Hospital Foundation

Question 9

Medicare and Medicaid programs required these programs starting in 1966.

Answer 9

utilization review

Question 10

Act of 1973 that was an effort by congress to address quality and cost of health care.

Answer 10

Health Maintenance Organization Act of 1973

Question 11

Managed care includes:

Answer 11

1. preferred provider organizations (PPO).

2. point of service

Question 12

What is the focus of managed care?

Answer 12

Quality of care and lower cost outcomes.

Question 13

These organizations were formed in 1972 to add an additional layer of review by professional standards organizations to impose an obligation on providers to support their provision of services.

Answer 13

professional standards review

Question 14

Allows enrollees to use non-affiliated providers for an additional fee

Answer 14

Point-of-Service

Question 15

Focuses on individual privacy rights.

Answer 15

HIPAA - Health Insurance Portability and Accountability Act

Question 16

What is the exception to patient privacy? (i.e. child abuse, infectious disease, dangers to third parties, etc.)

Answer 16

Mandatory reporting laws

Question 17

T/F Facilities generally own the records?

Answer 17

True

Question 18

T/F Managed care has encouraged electronic health records

Answer 18

True

Question 19

Accredits many types of healthcare entities including hospitals, healthcare networks, and PPOs. Has standards that govern the type of patient related data they collect.

Answer 19

Joint Commission on Accrediation of Healthcare Organizations (JCAHO)

Question 20

Accredits managed care organizations and has elaborate specific medical records standards that apply to this type of organization.

Answer 20

National Committee for Quality Assurance (NCQA)

Question 21

Joint Commission manual that addresses information management requiring PPOs to determine appropriate levels of security.

Answer 21

Accreditation Manual

Question 22

Why has the managed care been a stimulus for computerization of health information?

Answer 22

Require a centralized database for medical records.

Question 23

What is the statue that states the “record owner” refers to any healthcare practitioner who generates a medical records or who has records transferred from a prior practitioner?

Answer 23

Florida Statute 456.057 (a)

Question 24

How did Maryland under the state Medical Records Act define “healthcare” provider.

Answer 24

This includes HMOs, agents, employees, officers and directors of healthcare facilities.

Question 25

How is this different from the traditional definition?

Answer 25

More generic and less restrictive.

Question 26

Difference between HMO and PPO?

Answer 26

HMO finances and arranges health care services.

PPO used by employer benefit plans and insurance carriers to contract with participating providers.

Question 27

Compare and contrast PHO and MSO

Answer 27

PHO - Separate business entity. Contracts with hospital. Allows hospital and physicians to negotiate with third party providers.
MSO - Physicians remain independent contractors. Can be based around one or more hospitals.

Question 28

Two associations that accredit managed care organizations.

Answer 28

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and National Committee for Quality Assurance (NCQA)

Question 29

Basic principal of managed care.

Answer 29

Produce higher quality of care and lower cost outcomes.

Question 30

What is the purpose of the HMO model?

Answer 30

To furnish most, if not all, of the covered services “in-house” through physicians employed by and facilities owned by the HMO.

Question 31

Negotiates and manages rebates and price concessions from manufacturers or pharmacies.

Answer 31

pharmacy benefits managers (PBM)