U.S. Healthcare Insurance, Medicare & Managed Care Mastery Exam: PPO vs
HMO vs POS Plans, Gatekeeper Model, Network vs Out-of-Network Coverage,
Coinsurance & Copayments, Flexible Spending Accounts (FSA), Health Savings
Accounts (HSA), Capitation Payment Models, Revenue Cycle & Claims
Processing, Clean Claims vs Denials, Credentialing & Provider Enrollment,
National Provider Identifier (NPI), Medicare Parts A B C D, Medicare Advantage
Plans, Prescription Drug Coverage, Inpatient vs Outpatient Services, Home
Health Coverage Rules, Limiting Charge & Non-Participating Providers, Fee
Schedules & RBRVS Components, Relative Value Units (RVUs), Geographic
Practice Cost Index (GPCI), Conversion Factor, Medicaid Spenddown, Third-Party
Liability Billing, Workers’ Compensation & Liability Insurance, Self-Funded ERISA
Plans & Third-Party Administrators (TPA), Affordable Care Act (ACA) Appeals
Rights, Essential Health Benefits, Cosmetic Procedure Exclusions, Prior
Authorization & Precertification, Utilization Review, Medical Necessity Criteria,
Case Management, Managed Care Cost Control Strategies, Population Health &
ACO Models, Pioneer ACO Shared Savings Program, Integrated Delivery Systems
(IDS), Integrated Provider Organizations (IPO), Network Model HMO, Primary
Care Physician (PCP) Responsibilities, Specialist Referrals & Care Coordination,
Emergency Department Coverage Rules, Benefit Design & Coverage Restrictions,
CHIP (Children’s Health Insurance Program), TRICARE Exam Questions Verified
and Provided with Complete A+ Graded Rationales Latest Updated 2026
A patient needs to see a specialist for cardiac condition. She references her insurance handbook
for a list of network providers that belong to that specialty. She may choose any physician she
wishes and does not need a referral from her internist to see the specialist. If she chooses an
, out-of network physician, she will have to pay a higher co-insurance amount to see them. What
type of insurance is this?
PPO
An employee has signed up for a program through her employer. It allows her to put pre-tax
money away from her pay check in order to pay for out-of-pocket healthcare expenses. She may
contribute up to $2650 (2018) per year. If she does not use all of the money during the current
year, she refuses it. What is this?
Flexible Spending Account
what is the largest health program in the United States?
Medicare
A medicare beneficiary needing to fill a prescription would utilize what part of their medicare
benefits?
Part D
Managed care organizations (MCO's) place the physician at financial risk for the care of the
patient and are reimbursed by:
capitation
If a provider decides not to participate with medicare what is one of the disadvantages?
the patient receives the reimbursement
HMO vs POS Plans, Gatekeeper Model, Network vs Out-of-Network Coverage,
Coinsurance & Copayments, Flexible Spending Accounts (FSA), Health Savings
Accounts (HSA), Capitation Payment Models, Revenue Cycle & Claims
Processing, Clean Claims vs Denials, Credentialing & Provider Enrollment,
National Provider Identifier (NPI), Medicare Parts A B C D, Medicare Advantage
Plans, Prescription Drug Coverage, Inpatient vs Outpatient Services, Home
Health Coverage Rules, Limiting Charge & Non-Participating Providers, Fee
Schedules & RBRVS Components, Relative Value Units (RVUs), Geographic
Practice Cost Index (GPCI), Conversion Factor, Medicaid Spenddown, Third-Party
Liability Billing, Workers’ Compensation & Liability Insurance, Self-Funded ERISA
Plans & Third-Party Administrators (TPA), Affordable Care Act (ACA) Appeals
Rights, Essential Health Benefits, Cosmetic Procedure Exclusions, Prior
Authorization & Precertification, Utilization Review, Medical Necessity Criteria,
Case Management, Managed Care Cost Control Strategies, Population Health &
ACO Models, Pioneer ACO Shared Savings Program, Integrated Delivery Systems
(IDS), Integrated Provider Organizations (IPO), Network Model HMO, Primary
Care Physician (PCP) Responsibilities, Specialist Referrals & Care Coordination,
Emergency Department Coverage Rules, Benefit Design & Coverage Restrictions,
CHIP (Children’s Health Insurance Program), TRICARE Exam Questions Verified
and Provided with Complete A+ Graded Rationales Latest Updated 2026
A patient needs to see a specialist for cardiac condition. She references her insurance handbook
for a list of network providers that belong to that specialty. She may choose any physician she
wishes and does not need a referral from her internist to see the specialist. If she chooses an
, out-of network physician, she will have to pay a higher co-insurance amount to see them. What
type of insurance is this?
PPO
An employee has signed up for a program through her employer. It allows her to put pre-tax
money away from her pay check in order to pay for out-of-pocket healthcare expenses. She may
contribute up to $2650 (2018) per year. If she does not use all of the money during the current
year, she refuses it. What is this?
Flexible Spending Account
what is the largest health program in the United States?
Medicare
A medicare beneficiary needing to fill a prescription would utilize what part of their medicare
benefits?
Part D
Managed care organizations (MCO's) place the physician at financial risk for the care of the
patient and are reimbursed by:
capitation
If a provider decides not to participate with medicare what is one of the disadvantages?
the patient receives the reimbursement
