HSM 420 Midterm Exam

1.(TCO 1) Why were the first proto-HMOs formed in America? What were the original driving factors in the HMO movement? (Points : 20)

2.    (TCO 1) What is meant by indemnity coverage, and how does it change in managed indemnity? (Points : 20)

3.(TCO 2) What is the role of the executive director in a managed care organization? Could you see yourself practicing in this position at some point in your career? Why or why not? (Points : 20)

4.(TCO 2) What is the role of the Peer Review Committee in a managed care organization? And why is this function so crucial? (Points : 20)

5.(TCO 3) Describe the calculation of capitated payments. How are these rates determined in managed care organizations? (Points : 20)

6.(TCO 3) Describe the use of evidence-based clinical criteria in managed care. Why is this process so important in managed care today? (Points : 20) 

7.(TCO 4) What is meant by pattern review under managed care? Why do payers conduct pattern review, and what kinds of things might they identify during such reviews? (Points : 20)

8. (TCO 4) Discuss some key general aspects of physician practice behavior? Include implicit messages from training, and also environmental factors, in your answer. (Points : 20) 

9.(TCO 7) What is the purpose of hold-harmless and balance-billing clauses in managed care contracts? (Points : 20)

10.(TCO 7) What is typically covered under “term, suspension, and termination” of a managed care contract? (Points : 20)