Other Health Plans Chapter 17

Question 1

As a cost-containment method in medical plans, all of the following are examples of case management provisions except

A. second surgical opinion

B. reduction provision

C. concurrent review

D. precertification provision

Answer 1

B

Question 2

Traditional indemnity plans are characterized by all of the following except

A. billing and submission of claim forms for reimbursement

B. provision of care on a fee for service basis

C. the inclusion of a deductible and coinsurance requirement

D. the ability to access care from a specialist only with a referral from a primary care physician

Answer 2

D

Question 3

Which of the following statements about preferred provider organizations (PPOs) is not correct

A. PPO members select from among preferred provider for needed services

B. PPOs operate on a prepaid basis

C. A PPO is a group of health care providers, such as doctors, hospitals and ambulatory health care organizations that contracts with a group to provide their services

D. employers, insurance companies, and other health insurance benefit providers are typical groups that contract with PPOs

Answer 3

B

Question 4

What is another name for services provided to insureds at their residences?

A. long term care

B. adult day care

C. home health care

D. acute care

Answer 4

C

Question 5

All of the following are alternatives to hospital care except

A. intermediate nursing facilities

B. skilled nursing facilities

C. rehabilitative facilities

D. meal delivery programs

Answer 5

D

Question 6

Which of the following statements regarding persons participating in an HMO is correct?

A. they negotiate health care service fees with contracted HMO providers

B. they pay a fixed periodic fee whether or not health care services are used

C. they pay for health care services as they are incurred, at a rate discounted for the HMO

D. they pay for health care services as they are incurred

Answer 6

B

Question 7

A relatively small flat dollar amount that HMO subscribers pay for each doctor visit is known as

A. co-payments

B. coinsurance

C. deductibles

D. capitation fees

Answer 7

A

Question 8

HMOs may provide supplemental health care services. Which of the following is not a supplemental health care service?

A. vision care

B. dental care

C. outpatient care

D. home health care

Answer 8

C

Question 9

Which of the following is not a cost containment method used to reduce hospital care costs?

A. indemnification of medical expenses

B. preauthorization

C. outpatient benefits

D. mandatory second opinions

Answer 9

A

Question 10

All of the following groups may contract with PPOs except

A. employers

B. insurance companies

C. health insurance benefit providers

D. government programs

Answer 10

D

Question 11

Which of the following organizations contracts with select doctors and hospitals to be a health care provider for its members?

A. DPO

B. PPO

C. MIB

D. HMO

Answer 11

D

Question 12

Which of the following is the best reason why a medical plan would reuire a concurrent review for hospital patients?

A. the doctor and the patient consult on discharge times

B. the insurance company and the health care providers make decisions jointly

C. quality care is ensured at the most reasonable expense

D. the patient is discharged in the shortest possible time

Answer 12

C

Question 13

All of the following are examples of medical cost management except

A. mandatory second opinion

B. denying claims

C. precertification review

D. ambulatory surgery

Answer 13

B

Question 14

Lisa is in the hospital awaiting surgery. The doctors meet in the morning to discuss the best way to proceed as a routine procedure in their PPO. This is an example of

A. concurrent review

B. gatekeeping

C. provider credentiatiating

D. restrospective review

Answer 14

A

Question 15

All of the following are basic health care services offered by HMOs except

A. emergency care

B. inpatient hospital care

C. x-ray services

D. rehabilitative and home health services

Answer 15

D

Question 16

Cost-saving measures of managed care include all of the following except

A. unlimited mental and nervous benefits

B. annual physical visits

C. wellness programs

D. smoking cessation

Answer 16

A

Question 17

Which of the following statements accurately describes a health maintenance organization (HMO)?

A. it arranges for health care services for its members on a prepaid basis

B. it provides health insurance coverage specifically to people who cannot obtain coverage from insurance companies

C. it does not organize or deliver health care services

D. it is not required to be approved by the state before offering services to its subscribers

Answer 17

A

Question 18

Which of the following statements regarding health insurance benefits is correct?

A. the greater a policy’s benefits, the more expensive the premium

B. policyowners who have the same jobs pay the same premiums

C. premium amounts are determined only by the age of the insured

D. policyowners who have policies with identical benefits pay the same premiums

Answer 18

A

Question 19

Which of the following is a goal of managed care plans?

A. to fight fraud in the insurance business

B. to protect insureds from insolvency of health insurers

C. to provide low cost health care to people who could not ordinarily afford health insurance

D. to apply financial incentives that reduce the quantity and cost of services

Answer 19

D

Question 20

Which of the following statements pertaining to health maintenance organizations (HMOs) is correct?

A. HMOs are funded by the federal government, and eligibility is determined by the income levels of the participants

B. an HMO offers comprehensive services on a prepaid basis to its subscribing members

C. if a person joins an HMO and undergoes a physical examination, she will be billed for the exam and each subsequent medical service as it is performed

D. any insurance company that markets group health insurance is an HMO

Answer 20

B

Question 21

Which of the following is not an example of a managed care health plan?

A. PCP

B. HMO

C. POS

D. PPO

Answer 21

A

Question 22

To control costs, medical insurance plans available from commercial insurers and fraternal organizations are likely to provide care through

A. an HMO

B. a closed network PPO

C. an open network PPO

D. a Blue cross/blue shield plan

Answer 22

C

Question 23

Which of the following statements about point of service (POS) plans is true?

A. a POS plan does not require a primary care physician to manage in network care

B. a POS plan allows a subscriber to access care both in network and out of network

C. a POS plan does not include the use of a deductible or coinsurance

D. out of network care is billed on a prepaid basis

Answer 23

B

Question 24

Under what system do a group of doctors and hospitals in a designated area contract with an insurer to provide medical services at a prearranged cost to the insured?

A. DPO

B. PPO

C. HMO

D. MIB

Answer 24

B

Question 25

The most costly type of medical care is

A. outpatient benefits

B. home health care

C. prescription drug costs

D. inpatient hospitalization

Answer 25

D

Question 26

All of the following are considered to be viable medical plan cost saving options except

A. hospice care

B. skilled nursing facilities

C. emergency room preadmission testing

D. specialized birthing centers

Answer 26

C

Question 27

All of the following are methods to reduce hospital care costs except

A. nursing home benefits

B. outpatient benefit utilization

C. preauthorization and limits on length of stay

D. second surgical opinions

Answer 27

A

Question 28

Medical cost management is designed to

A. influence hospital charges and doctors fees

B. control health claims expenses

C. encourage people to seek medical help when other options are no longer available

D. discourage people from using health care services

Answer 28

B