Although the process is voluntary for health plans, external accreditation is becoming more and more important as states and purchasers require health plans undergo as many states and purchasers require health plans undergo some type of external review pr
A. Is voluntary for health plans.
B. Requires all change accreditation organizations to use the same standards of accreditation.
C. Typically requires the accrediting organization to conduct a medical record review and a review of a health plan's credentialing processes, but not an evaluation of the health plans' member service systems processes.
D. Cannot assure that a health plan meets a specified level of quality.
A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation must
A. Provide significant benefit to the community
B. Employ, rather than contract with, participating physicians
C. Achieve economies of scale through facility consolidation and practice management
D. Refrain from the corporate practice of medicine
Primary care case managers (PCCMs) provide case management services to eligible Medicaid recipients. With regard to PCCMs it is correct to say that:
A. PCCMs typically receive a case management fee, rather than reimbursement for medical services on a FFS basis, for the services they provide to Medicaid recipients.
B. All Medicaid recipients who live in rural areas must be given a choice of at least four PCCMs.
C. PCCMs receive a case management fee in addition to reimbursement for medical services on a FFS basis.
D. PCCMs contract directly with the federal government to provide case management services to Medicaid recipients.
Phoebe Urich is covered by a traditional indemnity health insurance plan that specifies a $500 calendar-year deductible and includes a 20% coinsurance provision. When Ms. Urich was hospitalized, she incurred $3,000 in medical expenses that were covered by
A. 1900
B. 2000
C. 2400
D. 2500
One characteristic of disease management programs is that they typically
A. focus on individual episodes of medical care rather than on the comprehensive care of the patient over time
B. are used to coordinate the care of members with any type of disease, either chronic or nonchronic
C. focus on managing populations of patients who have a specific chronic illness or medical condition, but do not focus on patient populations who are at risk of developing such an illness or condition
D. use clinical practice processes to standardize the implementation of best practices among providers
Primary care case managers (PCCMs) provide managed healthcare services to eligible Medicaid recipients. With regard to PCCMs, it is correct to say that
A. PCCMs contract directly with the federal government to provide case management services to Medicaid recipients
B. all Medicaid recipients who live in rural areas must be given a choice of at least four PCCMs
C. Medicaid PCCM programs are exempt from the Health Care Financing Administration's (HCFA's) Quality Improvement System for Managed Care (QISMC) standards
D. PCCMs typically receive a case management fee, rather than reimbursement for medical services on a FFS basis, for the services they provide to Medicaid recipients
The following statements are about federal laws that affect healthcare organizations. Select the answer choice containing the correct response.
A. The Women's Health and Cancer Rights Act (WHCRA) of 1998 requires health plans to offer mastectomy benefits.
B. The Health Care Quality Improvement Act (HCQIA) requires hospitals, group practices, and HMOs to comply with all standard antitrust legislation, even if these entities adhere to due process standards that are outlined in HCQIA.
C. The Newborns' and Mothers' Health Protection Act (NMHPA) of 1996 mandates that coverage for hospital stays for childbirth must generally be a minimum of 24 hours for normal deliveries and 48 hours for cesarean births.
D. Although the Mental Health Parity Act (MHPA) does not require health plans to offer mental health coverage, it imposes requirements on those plans that do offer mental health benefits.
Which is an advantage of a for-profit health plan?
A. Flexibility in raising capital
B. Double taxation
C. Exemption from paying federal income taxes.
D. None of the above.
A differences between managed indemnity and traditional indemnity
A. Include precertification and utilization review techniques
B. Both are the same
C. Include network and quality review techniques
D. A and B
The Oriole MCO uses a typical diagnosis-related groups (DRGs) payment method to reimburse the Isle Hospital for its treatment of Oriole members. Under the DRG payment method, whenever an Oriole member is hospitalized at Isle, Oriole pays Islet
A. an amount based on the weighted value of each medical procedure or service that Isle provides, and the weighted value is determined by the appropriate current procedural terminology (CPT) code for the procedure or service
B. a fixed rate based on average expected use of hospital resources in a given geographical area for that DRG
C. a retrospective reimbursement based on the actual costs of the Oriole member's hospitalization
D. a specific negotiated amount for each day the Oriole member is hospitalized
