Other Health Plans
3. David has a PPO that does not limit him to use only providers that have contracts with the PPO. David's PPO is A. open panel B. closed panel C. choice panel D. guarded panel
A. open panel
Second Surgical Opinion
Allows or requires consultation with a doctor other than their attending physician to see if an alternative method of treatment would be desirable
Preferred Provider Organizations
Another managed care entity that contracts with a network of medical practitioners to provide medical services for a fee that is somewhat lower than usual rates.
Preferred provider organizations
Are another managed care entity that provide medical services for a fee that is somewhat lower than the usual rate for that area
9. Which of the following alternatives to hospital care provides intermittent nursing care for patients who do not need 24 hour supervision? A. Skilled nursing facility B. Intermediate nursing facility C. Rehabilitative facility D. Home health care
B. Intermediate nursing facility
5. All of the following are characteristics of a PPO EXCEPT A. PPO's operate on a fee-for-service B. PPO's operate on a prepaid basis C. PPO's are typically open panel entities D. the relationship between a PPO and its providers is contractual
B. PPO's operate on a prepaid basis
Gwyneth's HMO requires that she receive health care services from a specified, limited number of health care providers chosen by the HMO. Gwyneth's HMO is A. open panel B. closed panel C. choice panel D. guarded panel
B. closed panel
6. If treatment requiring hospitalization is recommended, the physician of the insured may have to get the expense approved prior to obtaining the treatment. This is known as A. limits on lengths of stay B. preauthorization C. referral service D. outpatient benefits
B. preauthorization
The main difference between traditional health insurance arrangements and HMOs is that A. traditional health insurance companies provide both the health care service and the health care financing, but HMOs provide only the health care financing B. traditional health care insurance companies provide both the health care service and the health care financing, but HMOs provide only the health care service C. HMOs provide both the health care service and the health care financing, but traditional health care insurance companies provide only the financing D. HMOs provide both the health care service and the health care financing, but traditional health care insurance companies provide only the service
C. HMOs provide both the health care service and the health care financing, but traditional health care insurance companies provide only the financing
8. Which utilization management review is done after the treatment is complete? A. Prospective review B. Concurrent review C. Retrospective review D. Complete review
C. Retrospective review
4. All of the following are examples of managed care plans EXCEPT A. health maintenance organizations B. preferred provider organizations C. indemnity arrangements D. point-of-service plans
C. indemnity arrangements
10. All of the following statements about an HMO are correct EXCEPT A. HMO's control overutilization of their services by subscribers with the gatekeeper concept B. HMO subscribers are not free to choose any subscriber that they wish C. HMO's are managed care entities D. HMO's operate on a fee for service plan
D. HMO's operate on a fee for service plan
7. All of the following are points in the process of utilization management EXCEPT A. prospective review B. concurrent review C. retrospective review D. alternative review
D. alternative review
Open Panel
Entities and subscribers are not strictly limited to the plans providers
Closed-panel
Entities subscribers must seek care only from providers/physicians that belong to the HMO
Alternatives to Hospital Care
Facilities other than a hospital may provide a more appropriate level of care for some patients.
Health Maintenance Organizations
HMOs are managed care entities that provide both the health care service and the health care financing
Gatekeeper concept
How HMOs control overutilization of their services by subscribers is with the ______
Preauthorization
If treatment requiring hospitalization is recommended, Precertification is required prior to obtaining the treatment
Limits on Lenths of Stay
Insurers determined the appropriate number of days for various types of treatment. Limited payment to a certain number of days for a given procedure.
Co-payments
Is a relatively small, flat dollar amount that subscribers must pay for each doctor visit
Retrospective Review
Is done after treatment is complete. The outcome is evaluated to see if treatment was effective.
Prospective review
Occurs before an expensive test or treatment recommended by a physician is actually provided. Case is reviewed to determine necessity and cost-effectiveness
Utilization Management
Places oversight on the provision of medical care to make sure it is appropriate and effective
Outpatient Benefits
Procedures can be performed safely and effectively without the patient staying in the hospital overnight
Skilled nursing facilities
Provide round-the-clock care for patients who need inpatient supervision by a registered nurse.
Intermediate nursing facilities
Provides intermittent nursing care for patients who do need 24- hours supervision
Primary Care Physician
Subscribers choose a doctor with a general medical practice as there ______ and must see them first when seeking medical care
Concurrent review
Takes place while treatment is being provided. Insured's hospital stay is monitored to assure that everything proceeds to schedule
Home health care
is provided by agencies that employ a staff of nurses that make visits to a patient's home on a regular basis.
Point-of-Service Plans
plan is a type of HMO that allows subscribers to obtain care from providers who do not belong to the HMO as well as those who do
Rehabilitative facilities
provides a limited amount of medical care along with the personal care necessary for patients to recover from major surgeries, injuries or illnesses.
