Deck 3: Understanding Managed Care: Medical Contracts and Ethics

Question 1

Providers are likely to agree to discounted fee-for-service contracts because they result in a(n):

A) decrease in taxes paid by the physician.
B) increase in the number of patients referred to the physician.
C) decrease in paperwork required to file claims.
D) fewer administrative tasks for the medical office assistant.

Answer 1

increase in the number of patients referred to the physician.

Question 2

A managed care contract is considered a legal document between the:

A) provider and insurer.
B) provider and patient.
C) patient and insurer.
D) insurer and employer.

Answer 2

patient and insurer.

Question 3

Under a discounted fee-for-service arrangement, covered services are compensated at a:

A) discounted per-diem rate.
B) per-member-per-month rate.
C) reduced percentage of usual and customary charges.
D) reduced per-case rate.

Answer 3

reduced percentage of usual and customary charges.

Question 4

An increase in patient volume is often caused by:

A) discounted fee-for-service contracts.
B) per diem and per case contracts.
C) percentage of premium and capitation contracts.
D) capitation contracts.

Question 5

The schedule of benefits section of a managed care contract lists the:

A) deductible and coinsurance amounts that patients must pay.
B) providers in the contracted network.
C) medical services covered under the managed care plan.
D) benefits of participating in the managed care plan.

Question 6

Fee schedules in managed care contracts are increasingly based on:

A) Medicare's resource-based relative value scale (RBRVS) and conversion factor.
B) Medicare's resource-based relative value scale (RBRVS) with a different conversion factor.
C) the HMO's per-member-per-month guidelines.
D) usual and customary charges adjusted by geographic area.

Question 7

A medical office specialist must do all the following EXCEPT:

A) know the Patient Bill of Rights.
B) explain the ACO to the patient.
C) be familiar with managed care terms.
D) promote the provider network.

Question 8

According to some contract terms, if an MCO does not pay a claim within the time limit specified in the contract, the provider may be able to:

A) bill the patient directly.
B) charge the usual and customary fee instead of the discounted fee.
C) take legal action against the MCO.
D) terminate the MCO contract after filing a written notice of intention.

Question 9

Which type of payment method creates an incentive to provide more preventive care?

A) capitation
B) per diem
C) per case
D) discounted fee-for-service

Question 10

Contracts between the physician and managed care organization (MCO) are generally negotiated by the:

A) medical office specialist.
B) physician or upper management.
C) attorney.
D) account manager or business manager.

Question 11

ACO stands for:

A) affordable care organization.
B) acute care organization.
C) accountable care organization.
D) assurance care organization.

Question 12

Which of the following is NOT a common type of payment arrangement in a managed care contract?

A) discounted fee-for-service
B) annual fee
C) capitation
D) per case

Question 13

A contract with which of the following payment terms can result in an increased financial risk to the provider?

A) capitation
B) percentage of premiums
C) fee-for-service
D) discounted fee-for-service

Question 14

Provisions included in a managed care contract with a provider include:

A) what is expected of the provider.
B) time limits for submitting claims.
C) reimbursement amounts.
D) all of the above.

Question 15

A managed care contract should clearly state all of the following EXCEPT:

A) how much the physician will be paid for services.
B) when payment should be received from the MCO.
C) the time limit for submitting claims to the MCO.
D) the list of employers with MCO contracts.

Question 16

A managed care contract will include a:

A) list of patients covered by the plan.
B) list of physicians in the network.
C) description of what types of employer groups are offered coverage.
D) description of how the physician will be paid for services.

Question 17

A provider who enters into a contract with an MCO is referred to as a(n):

A) active provider.
B) MCO provider.
C) participating provider.
D) permanent provider.

Question 18

Managed care organizations (MCOs) develop a network by contracting with:

A) physicians.
B) facilities.
C) pharmacies.
D) all of the above.

Question 19

Under a contract based on a per-case or per-visit rate of compensation, the provider is paid a predetermined rate for each:

A) enrolled patient.
B) episode of care.
C) diagnosis code.
D) service provided.

Question 20

The benefits of a managed care contract to the provider include:

A) keeping costs down.
B) bringing more patients to the practice.
C) adding opportunities for staff development.
D) increasing administrative duties.

Question 21

Emergency services are warranted if the absence of immediate medical attention could result in:

A) placing the covered person's health in serious jeopardy.
B) serious impairment to bodily functions.
C) serious dysfunction of any bodily organ or part.
D) all of the above.

Question 22

The following is true of Obamacare:

A) preventative care is more accessible.
B) employers are mandated to furnish healthcare or be fined.
C) requires all insurance plans to cover contraceptives at no cost.
D) all of the above.

Question 23

In cases of fraudulent billing:

A) only the physician can be held liable.
B) the physician can never be held liable.
C) the medical office specialist can be held liable.
D) the medical office specialist can never be held liable.

Question 24

What is the key component of an accountable care organization?

A) It receives an annual fee from their patients.
B) It receives a lump sum fee from a government plan.
C) It receives a retainer from their patients.
D) It receives an annual fee from Medicare.

Question 25

An MCO may contract with a physician whose background is questionable in order to:

A) contract with all the providers in a given area.
B) make the network as large as possible.
C) ensure that all specialties are available in the network.
D) An MCO would never contract with a physician who has a questionable reputation.

Question 26

When a person has health insurance coverage through two or more plans, the determination of which plan will provide benefits as primary or secondary payer is known as:

A) case management.
B) benefit determination.
C) coordination of benefits.
D) coordination of services.

Question 27

A medical office specialist works as a liaison between: (Select all that apply)

A) the provider and patient.
B) the provider and carrier.
C) the patient and employer.
D) the employer and carrier.

Question 28

The Affordable Care Act represents the most significant overhaul of the U.S. healthcare system since:

A) the passing of Medicaid.
B) the passing of Medicare.
C) the passing of Obamacare.
D) Both A and B.

Question 29

A managed care organization (MCO) uses a credentialing process to evaluate a provider's:

A) medical credentials.
B) service fees.
C) workplace environment.
D) all of the above.

Question 30

All the following are true regarding an ACO EXCEPT:

A) It shares the patient's information with its network of providers.
B) It needs a patient's authorization to release medical information.
C) It is part of a Medicare Advantage plan.
D) It participates in a Medicare Shared Savings Program.

Question 31

The organization that awards accreditation to managed care organizations is the:

A) Centers for Medicare and Medicaid Services (CMS).
B) National Center for Competency Testing (NCCT).
C) National Committee for Quality Assurance (NCQA).
D) World Health Organization (WHO).

Question 32

In MCOs, the business aspects of healthcare are not being controlled by:

A) physicians.
B) managers.
C) accountants.
D) actuaries.

Question 33

Services provided to treat a medical condition that involves the sudden onset of acute symptoms of sufficient severity to threaten a person's life or health are:

A) urgent care.
B) medical care.
C) hospital care.
D) emergency care.

Question 34

With respect to National Committee for Quality Assurance (NCQA) accreditation:

A) MCOs must be accredited to operate.
B) MCOs have all asked to be accredited, but some do not qualify.
C) some MCOs are accredited, and some are not.
D) accredited MCOs are always better than nonaccredited MCOs.

Question 35

Medically necessary services include all of the following EXCEPT services that are:

A) experimental, investigative, or unproven.
B) based on recognized standards of the specialty involved.
C) not solely for the convenience of a covered person or a healthcare provider.
D) accepted by the healthcare profession as appropriate and effective for the condition being treated.

Question 36

In plans that require the primary care physician (PCP) to play a gatekeeper role, the PCP is given incentives to:

A) expand office hours and/or staff to permit more patients to be seen each day.
B) make frequent referrals to contracted network specialists.
C) see as many patients each day as possible, even if this means less time with each patient.
D) treat the patient as much as possible without a specialist referral unless absolutely necessary.

Question 37

The maximum allowable fee payable for the provision of a particular contracted service by a physician is called the:

A) reimbursement rate.
B) negotiated fee.
C) fee maximum.
D) capitation rate.

Question 38

The credentialing process of a managed care organization (MCO) will examine each physician's background for evidence of all of the following EXCEPT:

A) criminal activity.
B) disciplinary actions.
C) malpractice history.
D) salary history.

Question 39

Business values incorporated into medical practices as a result of managed care include a(n):

A) emphasis on the doctor-patient relationship.
B) return to fee-for-service payments.
C) focus on efficiency, cost reduction, and profit.
D) focus on administrative requirements and paperwork.

Question 40

The contract issued by a payer, the plan document, or any other legally enforceable instrument under which a covered person may be entitled to covered services is called:

A) the schedule of benefits.
B) the benefit plan.
C) covered services.
D) contracted services.

Question 41

The healthcare professional in a medical practice or billing office who is responsible for submitting insurance claims may be known as a medical office specialist.

Question 42

ACOs are a group of insurance providers.

Question 43

Providers are not required to sign a contract with a managed care plan in order to become part of the plan's provider network.

Question 44

In the Patient's Bill of Rights under the Affordable Care Act, which service(s) are covered with no cost to patients? (Select all that apply)

A) immunizations.
B) mammograms.
C) chemotherapy.
D) colonoscopies.

Question 45

A policyholder in a managed care contract is also called a member or enrollee.

Question 46

The contract provision that states a physician cannot seek payment from a patient under a managed care contract in relation to any benefit penalties that were applied based on a utilization review decision is:

A) no fault.
B) hold harmless.
C) stoploss coverage.
D) liability.

Question 47

An individual who is an insured, enrolled subscriber or dependent under the terms of a health benefit plan is a(n):

A) contracted entity.
B) covered person.
C) payer.
D) provider.

Question 48

Under an ACO contract physicians receive a fee for each service they perform.

Question 49

Principles adopted in the Patient's Bill of Rights include all of the following EXCEPT the right to:

A) accurate and easily understood information.
B) receive emergency services without penalty.
C) know your treatment options.
D) sue the managed care organization.

Question 50

According to the new Patient's Bill of Rights, the following is true regarding emergency care:

A) companies can limit which emergency department the patient goes to.
B) new plans cannot penalize for out of network care.
C) there may be a financial penalty for non-network care.
D) the primary care physician must approve emergency care.

Question 51

All of the following regarding the Patient's Bill of Rights are true EXCEPT:

A) Patients joining a new plan can choose their own doctor in the insurer network.
B) Patients can receive preventative care without paying deductibles, coinsurance, or copayments.
C) Patients have the right to appeal an insurance company decision with an independent third party.
D) Patients may receive financial reimbursement for out of network penalties.

Question 52

Which of the following are new laws in the Patient's Bill of Rights under the Affordable Care Act?

A) no one can be denied coverage because of a pre-existing medical condition.
B) a patient cannot be dropped from coverage due to an unintentional mistake on their application.
C) insurance companies can no longer put a lifetime limit of the amount of coverage.
D) all of the above.

Question 53

Most managed care contracts allow an unlimited time frame for submitting claims.

Question 54

All of the following are true regarding the concierge contract EXCEPT:

A) It may not be required to abide by the Bill of Rights.
B) It is a legal agreement between patient and provider.
C) It is a cash only agreement between the provider and patient.
D) It may require the patient to pay the provider a retainer.

Question 55

Types of payment arrangements in managed care contracts include discounted fee-for-service, per diem, per case, percentage of premiums, and capitation.

Question 56

In the Patient's Bill of Rights under the Affordable Health Care Act, young adults who are not offered coverage at work are covered by their parents' plan until they reach:

A) 19.
B) 21.
C) 25.
D) 26.

Question 57

Managed care contracts never prohibit the provider from seeking payment directly from plan members.

Question 58

Which of the following is true of the new Patient's Bill of Rights under the Affordable Health Care Act?

A) Insurance companies are banned from restricting emergency room care.
B) Insurance companies are prohibited from charging patients for preventative care.
C) Insurance companies are banned from limiting choice of doctors.
D) all of the above.

Question 59

A payer that is contractually obligated to make payment for medical services on behalf of the covered person can be:

A) an insurance company.
B) a third-party administrator.
C) a self-insured health benefit plan.
D) all of the above.

Question 60

A managed care contract that involves payment through capitation provides incentives for physicians to emphasize preventive care.

Question 61

A ________ contract is another form of a legal agreement between the provider and the patient under which the patient pays the provider an annual fee or retainer.

Question 62

The Patient's Bill of Rights under the Affordable Care Act put an end to insurance companies limiting choice of doctors.

Question 63

Under a discounted fee-for-service arrangement, covered services are compensated at a discount of the provider's ________ charges.

Question 64

The list of medical services covered under the insured's policy is called the schedule of ________.

Question 65

A medical office specialist cannot be held liable for fraudulent billing practices if told to do so by a physician.

Question 66

Determination of which of two or more health plans will provide benefits as primary or secondary payer is known as coordination of benefits.

Question 67

Under an ACO the member can use any doctor or hospital that accepts Medicare.

Question 68

Patients do not have the right to receive emergency services outside of their contracted network.

Question 69

The charge a covered person is required to pay at the time covered services are provided is called a(n) ________.

Question 70

A managed care contract specifies covered services, reimbursement amounts, and the method of ________ for the contracted physician.

Question 71

When a managed care organization (MCO) examines a physician's background for evidence of fraud or criminal activity, this is part of the process known as ________.

Question 72

Concierge medicine is a small, personalized medical practice that takes care of a limited number of patients.

Question 73

A medical office specialist should always document, sign, and date all conversations regarding any patient's account.

Question 74

An increasing number of managed care plans are basing fee schedules on the Medicare ________.

Question 75

Under a managed care contract, physicians cannot balance bill or impose any surcharge upon covered persons.

Question 76

A managed care organization will contract with physicians, laboratories, pharmacies, hospitals, clinics, and other healthcare facilities in building a provider network.

Question 77

The organization that awards accreditation to health plans for meeting quality standards of healthcare delivery is the ________.

Question 78

Patients are typically very familiar with their health plan benefits when discussing claims issues with the medical office specialist.

Question 79

In order to receive National Committee for Quality Assurance (NCQA) accreditation, a managed care organization (MCO) must demonstrate that it has a thorough credentialing process.

Question 80

PMPM stands for________.