Healthcare Management: An Introduction v4.0

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Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network.
Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim

  • A. A, B, C, and D
  • B. A and C only
  • C. A, B, and D only
  • D. B, C, and D only


Answer : A

Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:

  • A. Codes
  • B. Lists
  • C. Edits
  • D. Checks


Answer : C

In the paragraph below, a sentence contains two pairs of words enclosed in parentheses.
Determine which word in each pair correctly completes the sentence. Then select the answer choice containing the two words that you have chosen. Many pharmacy benefit

  • A. Therapeutic / always
  • B. Generic / always
  • C. Generic / never
  • D. Therapeutic / never


Answer : A

Health plans can organize under a not-for-profit form or a for-profit form. One true statement regarding not-for-profit health plans is that these organizations typically

  • A. are exempt from review by the Internal Revenue Service (IRS)
  • B. are organized as stock companies for greater flexibility in raising capital
  • C. rely on income from operations for the large cash outlays needed to fund long-term projects and expansion
  • D. engage in lobbying or political activities in order to maintain their tax-exempt status


Answer : C

Brokers are one type of distribution channel that health plans use to market their health plans. One true statement about brokers for health plan products is that, typically, brokers

  • A. Are not required to be licensed by the states in which they market health plans
  • B. Are compensated on a salary basis
  • C. Represent only one health plan or insurer
  • D. Are considered to be an agent of the buyer rather than an agent of the health plan or Insurer


Answer : D

Consumer-directed health plans are not a new concept. They actually got their start in the late 1970s with the advent of:

  • A. Health savings accounts (HSAs)
  • B. Health reimbursement arrangements (HRAs)
  • C. Medical savings accounts (MSAs)
  • D. Flexible spending arrangements (FSAs)


Answer : D

From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence

  • A. Health plans and their providers are obligated not to harm their members
  • B. Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a group
  • C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members
  • D. Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives


Answer : B

Ian Vladmir wants to have a routine physical examination to ascertain that he is in good health. Mr. Vladmir is a member of a health plan that will allow him to select the physician of his choice, either from within his plan's network or from outside of h

  • A. a traditional HMO plan
  • B. a managed indemnity plan
  • C. a point of service (POS) option
  • D. an exclusive provider organization (EPO)


Answer : C

All CDHP products provide federal tax advantages while allowing consumers to save money for their healthcare.

  • A. True
  • B. False


Answer : A

The following statements describe two types, or models, of HMOs:
The Quest HMO has contracted with only one multi-specialty group of physicians. These physicians are employees of the group practice, have an equity interest in the practice, and provide

  • A. A captive group a staff model
  • B. A captive group a network model
  • C. An independent group a network model
  • D. An independent group a staff model


Answer : B

Ashley Martin is covered by a managed healthcare plan that specifies a $300 deductible and includes a 30% coinsurance provision for all healthcare obtained outside the plans network of providers. In 1998, Ms. Martin became ill while she was on vacation,

  • A. $300
  • B. $510
  • C. $600
  • D. $810


Answer : D

Before the Hill Health Maintenance Organization (HMO) received a certificate of authority
(COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

  • A. Hill had to have an initial net worth of at least $1.5 million in order to obtain a COA.
  • B. The COA most likely exempts Hill from any of State X's enabling statutes.
  • C. Hill had to be organized as a partnership in order to obtain a COA
  • D. The COA in no way indicates that Hill has demonstrated that it is fiscally sound.


Answer : A

In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known

  • A. dual choice
  • B. cost shifting
  • C. accreditation
  • D. defensive medicine


Answer : B

Because many patients with behavioral health disorders do not require round-the-clock nursing care and supervision, behavioral healthcare services can be delivered effectively in a variety of settings. For example, post-acute care for behavioral health di

  • A. Hospital observation units or psychiatric hospitals.
  • B. Psychiatric hospitals or rehabilitation hospitals.
  • C. Subacute care facilities or skilled nursing facilities.
  • D. Psychiatric units in general hospitals or hospital observation units.


Answer : C

By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an
HMO provides comprehensive care include

  • A. coordinating care across a variety of benefits
  • B. emphasizing preventive care by covering many preventive services either in full or with a small copayment
  • C. offering its members access to wellness programs
  • D. All of the above


Answer : D

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