HSA4109 Practice Quizzes 1-5
Which of the following is an example of an early prepaid group practice?
-Ross-Loos Clinic -Farmers' cooperative health plan in Oklahoma -Western Clinic in Tacoma
Pair the regulator to the type of health insurance plans it regulates. 1. Medicare 2. Medicaid 3. State Departments of Insurance (DOIs)
1. The Centers for Medicare and Medicaid Services (CMS) 2. State Medicaid Agencies 3. Private Health Plans
What organization formed a council on medical education to set physician licensure standards?
American Medical Association
Which of the following is NOT a source of evidence-based medicine practice guidelines for determining whether services are medically necessary?
Anecdotal information from the press
Which of the following may be used by insurance companies to determine payment rates for out-of-network providers?
Both Usual Customary and Reasonable (UCR) and Medicare fee schedule (RBRVS)
Which of the following describes how fees are listed in a fee schedule?
Both by CPT and HCPCS codes
Under which of the following payment methods would a provider earn more money by serving more insured health plan members each month?
Capitation
Which of the following types of payment models tend to be more predictable and less expensive?
Capitation
Which of the following is a type of retrospective utilization management?
Case review
Which of the following laws provided temporary insurance for people in-between jobs?
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Which of the following is a type of concurrent utilization management?
Continued-stay review
Which of the following is NOT typically excluded from benefits in health plans?
Dental/vision for children
Which of the following employers will have to provide health insurance for its employees due to the ACA employer mandate?
Employer with 100 full-time employees
True or False: An allowable fee is defined as the minimum amount an insurance company will pay for a service.
False
True or False: Congress created the National Association of Insurance Commissioners (NAIC) to develop medical loss ratios (MLRs).
False
True or False: Cost sharing can be used in benefit design to reduce utilization of non-medically necessary services, but it cannot be used to increase utilization of preventive services.
False
True or False: If you accept COBRA coverage and then decide 4 months later that you would rather enroll in a health plan on the Health Insurance Exchange, you can do so through a special enrollment period.
False
True or False: In most organizations, nurses handle all calls, including service and payment denials.
False
True or False: Individual healthcare providers have more contract negotiating power than health insurance companies.
False
True or False: Medicare is moving towards more retrospective payment systems.
False
True or False: Providers must be recredentialed every year.
False
True or False: The American Medical Association supported the creation of Medicare and Medicaid?
False
True or False: The Employee Retirement Income Security Act (ERISA) requires employers to offer employees health insurance.
False
True or False: The medical loss ratio for small group and individual health plans is 85%.
False
Which of the following types of payment methods is based on volume?
Fee-for-service
Which of the following came first?
First HMO (Ross-Loos Clinic)
Which of the following is the strictest form of health insurance?
Health Maintenance Organization (HMO)
As the government mandates insurance companies to add more benefits, health insurance premiums are likely to be impacted and:
Increase
Choose the answer that best fills in the blank: If a health plan purchases reinsurance then ______________?
It has protection against extremely high costs.
Which of the following is an advantage to a health insurance company of contracting with an independent practice association (IPA)?
Many providers are included in a single contract
Did the Affordable Care Act (ACA) protect consumers from balance billing for situation where the patient is unable to choose an in-network provider?
No
Which of the following statements regarding market consolidation is true? If providers or hospitals merge together and consolidate then market competition increases If providers or hospitals merge together and consolidate then premiums will likely decrease When providers and hospitals merge together and consolidate there is no impact on market competition, nor premiums
None
Which of the following is a public payer? -Employer -Patient -Provider
None of the answers are correct
Is the following scenario considered to be a preventive service where the patient cannot be charged cost sharing? "A man makes quarterly visits to his doctor to check his cholesterol levels to check his medication dosage is appropriate. Is the service considered preventive?"
Not preventive, patient may pay cost sharing
Is the following scenario considered to be a preventive service where the patient cannot be charged cost sharing? "A woman visits a doctor in her network for a mammogram, but the results prompt the doctor to ask her to come back for a follow-up visit and a follow-up mammogram. Is the follow-up service considered preventive?"
Not preventive, patient may pay cost sharing
Is the following scenario considered to be a preventive service where the patient cannot be charged cost sharing? "A man receives a blood test to determine his blood cholesterol level at his annual wellness exam. Is the service considered preventive?"
Preventive, patient pays no cost sharing
Is the following scenario considered to be a preventive service where the patient cannot be charged cost sharing? "A woman visits a doctor in her network for an annual mammogram. Is the service considered preventive?"
Preventive, patient pays no cost sharing
Which of the following is a type of prospective utilization management?
Prior authorization
Which of the following is an example of a typical disease management program?
Programs to manage high-risk pregnancies
Which type of payment is used for in-network provider?
Prospective
Which of the following payment types is used after a service has occurred?
Retrospective
Which of the following laws provided "Old Age" benefits?
Social Security Act
Which of the following terms describes when a patient is unable to choose an in-network provider and receives a bill for an out-of-network provider?
Surprise bill
Which of the following statements regarding the HMO Act is true?
The law provided funding for HMO development
True or False: Because Kylie is sick she is more likely than healthy Ben to buy health insurance. This is known as adverse selection.
True
True or False: Capitation is always prospective.
True
True or False: Dr. Jones is an out-of-network provider whose claim for payment is denied. There was no previous discussion between the health plan and Dr. Jones related to providing this service. This is an example of retrospective utilization management.
True
True or False: Explanation of Benefits (EOB) documents are created when a provider submits a claim.
True
True or False: One of the concerns with fee-for-service is that it may incentivize providers to prescribe non-medically necessary services.
True
True or False: The American Medical Association preferred individual fee-for-service payments rather than prepaid groups.
True
True or False: Typically, utilization management includes a 2-stage assessment beginning with screening by UM nurses and then physician review.
True
True or False: Under capitation, providers are paid regardless of whether they see an insured health plan member or not.
True
Can fee-for-service be used prospectively?
Yes
Can out-of-network providers balance bill patients?
Yes
Choose the answer that best fills in the blank: If a health plan charges consumers different premium rates in the individual health plan market, it is violating _____________________ provisions under the Affordable Care Act (ACA).
community rating
What do state departments of insurance regulate? Solvency Provider networks Medical loss ratio
All are correct
When a health insurance plan or employer contracts with a Center of Excellence, which of the following is a likely outcome? Better employee morale and less employee turnover Fewer post-surgical complications Fewer medical errors More costs to the health plan or employer in the short term, but savings over the long term Better long-term health outcomes
All correct
If a risk pool has more unhealthy, rather than healthy individuals that experience catastrophic health events enrolling each year, an insurance company may face:
A death spiral
Which of the following is a main area of focus for utilization management? Determining services that are covered and under which circumstances they are covered Promoting the use of services at the lowest reasonable cost Promoting the use of services that best improve health outcomes
All Correct
