Other Health Plans

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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.


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