for DR.SAMUELSON only!!!!
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week4-midterm-smhs.docxWeek#4-Quiz-SMHS
1. Prior to the 1970s, health maintenance organizations (HMOs) were known as:
A.
Point-of-service programs
B.
Referred provider organizations
C.
Prepaid group practices
D.
None of the above
2. Capitation is usually defined as:
A.
Prepayment for services on a fixed, per member per month basis
B.
Fee-for-service including withhold provisions
C.
Performance based compensation system
D.
Stop-loss reinsurance provisions
3. Which organization(s) need a Corporate Compliance Officer (CCO)?
A.
Health plans with a Medicare Advantage risk contract
B.
Every organization that provides health care
C.
Hospitals
D.
All of the above
E.
A and C
4. Which of the following organizations may conduct primary verification of a physician’s credentials?
A.
HMO
B.
PPO
C.
CVO
D.
An accreditation organization such as NCQA, URAC or AAAHC
E.
All of the above
F.
A, B and C only
5. Payment to a facility for outpatient procedures may be increased on a case-by-case basis through which of the following?
A.
Outliers
B.
Carve-outs
C.
A and B
D.
None of the above
6. The use of the word “whereas” in most legal contracts is merely tradition and has NO legal significance.T/F?
7. The use of utilization guidelines targets only managed care patients and does not have an impact on the care of non–managed care patientsT/F?
8. Costs of non-catastrophic, recurring outpatient care have risen significantly in the past few decades.T/F?
9. The most effective way to induce behavior changes in physicians is through continuing medical education.T/F?
10. The goal of risk adjustment is to separate the effect of treatment from characteristics inherent to members.T/F?
11. In January 2006, what large federal prescription drug program was implemented that offered pharmacy benefits to more than 40 million people at that time and is expected to increase by 30% throughout the next decade?
A.
The Department of Defense TRICOR program
B.
State Medicaid programs
C.
Public Health Service and Indian Health Service
D.
Medicare Part D
12. Which organization does not accredit managed behavioral health care companies?
A.
NCQA
B.
JCAHO
C.
American College of Mental Health Administration
D.
URAC
E.
Council on Accreditation
13. Give an example of a program that can be offered by a health plan to help members change high-risk behaviors._____________
14. All managed care plans are required by the federal government to participate in accreditation and performance measurement programs.T/F?
15. What are intermediaries in the employer-sponsored business called?
A.
Brokers
B.
Consultants
C.
A and B
D.
Suppliers
16. The Institute of Medicine’s Committee on the Quality of Health Care in America proposed six aims for improvement in our health care system. Name the six aims:
___,___,___,___,___,___.
17. An application for enrolling in a Medicare Advantage plan is referred to as__________.
18. The four primary claims core competencies are:___,___.___,___.
19. Common types of health care fraud include:
A.
Billing for services not performed
B.
Billing for more drugs than dispensed
C.
Duplicate billing
D.
Prevention of congestive heart failure
E.
Identity theft to obtain care
F.
Forging prescriptions
G.
All of the above
H.
All of the above except D
20. Member services is responsible for all of the following activities, except:
A.
Adjudicating claims
B.
Enhancing the relationship between the members of the plan and the plan itself
C.
Handling member grievances and complaints
D.
Providing information to members
