Deck 3: Understanding Managed Care: Medical Contracts and Ethics

Question 1

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.

Answer 1

physician or upper management.

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

provider 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

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 5

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.

Question 6

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 7

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 8

RBRVS stands for:

A)resource-based relative value scale.
B)resource-based rates of valued services.
C)rates by resources and value scale.
D)relative buying rates for valued services.

Question 9

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 10

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

A)Discounted fee-for-service
B)Usual and customary
C)Capitation
D)Per case

Question 11

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 12

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)a listing of eligible patients

Question 13

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 14

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 15

MCOs develop a network by contracting with:

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

Question 16

With respect to a managed care contract, a medical office specialist is responsible for understanding the:

A)administrative requirements of submitting claims and time frames for payment.
B)process used to determine the fee schedule.
C)MCO's plans for advertising and promoting the provider network.
D)ownership and financial status of the MCO.

Question 17

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 18

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 19

An increase in patient volume often results from:

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

Question 20

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 21

A medical office specialist works as a liaison between:

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

Question 22

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 23

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

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

Question 24

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 25

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 26

One aspect of healthcare reform that most people agree on is that:

A)the cost of healthcare delivery is likely to decrease in the next decade.
B)managed care will not be a long-term trend.
C)the specific scope of necessary changes has been determined.
D)reform needs to address issues of cost, access, and quality of care.

Question 27

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 28

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 29

The following is true of a managed care system:

A)The patient's choice of provider is determined by the terms of the plan.
B)The patient's choice of provider is completely at his or her discretion.
C)The physician has less latitude in providing services.
D)Both a and c.

Question 30

Through a credentialing process, a managed care organization (MCO) evaluates a provider's:

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

Question 31

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 32

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 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

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 35

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 and not refer him/her to a specialist unless absolutely necessary.

Question 36

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 37

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 38

The healthcare delivery system involves a relationship between:

A)patients and providers.
B)providers and third-party payers.
C)patients and third-party payers.
D)patients, providers, and third-party payers.

Question 39

Business values that are being incorporated in 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

In a system based on managed care, the patient's choice of provider is:

A)dictated by his or her geographic location.
B)dictated by his or her income.
C)more limited than under a traditional fee-for-service structure.
D)less limited than under a traditional fee-for-service structure.

Question 41

The Patient's Bill of Rights was adopted in 1998 by the:

A)National Committee for Quality Assurance (NCQA).
B)Centers for Medicare and Medicaid Services (CMS).
C)U.S. Advisory Commission on Consumer Protection and Quality in the Health Care Industry.
D)U.S. Surgeon General.

Question 42

The provision in the Patient's Bill of Rights that allows patients the right to review and copy their own medical records is called:

A)information disclosure.
B)participation in treatment decisions.
C)respect and nondiscrimination.
D)confidentiality of health information.

Question 43

The U.S. healthcare system can no longer accommodate unlimited demand for medical services.

Question 44

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 45

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 46

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

Question 47

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

Question 48

Discounted fee-for-service arrangements can discourage a provider from ordering multiple tests and providing a higher level of services.

Question 49

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

A)the care must be received in a contracted facility.
B)the care can include all services for that episode.
C)the care can include screening and stabilization of the patient's condition.
D)there may be a financial penalty for non-network care.

Question 50

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

Question 51

Which of the following is true of the Patient's Bill of Rights?

A)It is a written contract between the patient and provider.
B)All MCOs have formally agreed to abide by its principles.
C)It is an ethical standard adopted by an advisory commission on healthcare consumer protection.
D)It is included in the physician's professional oath.

Question 52

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)a sufficient choice of healthcare providers.
C)receive emergency services without prior authorization.
D)sue the managed care organization.

Question 53

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 54

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 55

Most managed care contracts allow an unlimited timeframe for submitting claims.

Question 56

In the Patient's Bill of Rights, information disclosure provides patients with the right to information that is:

A)easily understood in English only.
B)translated into all languages spoken in the United States.
C)easily understood in English, French, and Spanish.
D)explained with assistance for non-English-speakers, people with disabilities, or those who need help for other reasons.

Question 57

Under managed care contracts, the patient's choice of providers is usually more extensive than in traditional fee-for-service.

Question 58

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

Question 59

In the Patient's Bill of Rights, the provision regarding choice of providers allows patients the right to:

A)use any network or non-network providers.
B)a network with access to appropriate high-quality healthcare.
C)a network that allows second opinions from non-network providers.
D)a network that includes all the physicians in a given area.

Question 60

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

Question 61

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

Question 62

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

Question 63

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

Question 64

PMPM stands for __________ .

Question 65

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

Question 66

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

Question 67

A managed care contract is a legal agreement between a healthcare __________ and a(n) __________ organization.

Question 68

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

Question 69

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

Question 70

If a managed care organization (MCO) pays the hospital for physician services rendered in the facility, it is the physician's responsibility to seek reimbursement from the hospital.

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

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

Question 73

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

Question 74

A set of ethical standards designed to protect patients is known as the Patient's __________ .

Question 75

Patients have the right to file a complaint about a physician or a healthcare facility in regard to waiting times or poor conduct by personnel.

Question 76

"Medically efficient" used in contract language may have the same meaning as "medically necessary."

Question 77

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

Question 78

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

Question 79

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

Question 80

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.