Other Health Plans Chapter 17 Flashcards
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
B
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
D
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
B
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
C
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
D
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
B
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
A
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
C
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
A
All of the following groups may contract with PPOs except
A. employers
B. insurance companies
C. health insurance benefit providers
D. government programs
D
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
D
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
C
All of the following are examples of medical cost management except
A. mandatory second opinion
B. denying claims
C. precertification review
D. ambulatory surgery
B
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
A
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
D
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
A
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
A
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
A
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
D
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
B
Which of the following is not an example of a managed care health plan?
A. PCP
B. HMO
C. POS
D. PPO
A
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
C
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
B
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
B
The most costly type of medical care is
A. outpatient benefits
B. home health care
C. prescription drug costs
D. inpatient hospitalization
D
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
C
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
A
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
B
