Revenue Cycle Final Exam Study Guide 1 with complete
solution
Triple option plans are intended to prevent the problem of covering members who
are sicker than the general population, which is called __________ selection
Adverse
A group practice without walls (GPWW) establishes a contract that allows
physicians to maintain their own offices and share services, such a
appointment scheduling and billing
Which is a review for medical necessity of inpatient care prior to the patient's
admission
preadmission certification
Which involves arranging appropriate health care services for the patient who is
being released from an inpatient hospitalization
discharge planning
Which is created when a number of people are grouped for insurance purposes
and the cost of health care coverage is determined by employees' health status,
age, sex, and occupation
risk pool
Which is usually offered either by a single insurance plan or as a joint venture
among two or more insurance payers and provides subscribers or employees
with a choice of HMO, PPO, or traditional health insurance plans
triple option plan
Which is a review that grants prior approval for reimbursement of a health care
service
Preauthorization
Which is associated with contracted health care services that are delivered to
subscribers by participating physicians who are members of an independent
multispecialty group practice
group model HMO
A triple option plan is also called a __________ or flexible benefit plan because of
the different benefit plans and extra coverage options provided through the
insurer or third-party administrator
cafeteria plan
Prior to scheduling elective surgery, managed care plans often require a
__________ during which another physician is asked to evaluate the necessity of
surgery and recommend the most economical, appropriate facility in which to
perform the surgery
second surgical opinion
Which program resulted from the Balanced Budget Act of 1997 (BBA) and
requires that quality assurance activities are performed to improve the
functioning of Medicare Advantage (Medicare Part C) organizations
quality assessment and performance improvement (QAPI)
,Which is associated with health care that is provided in an HMO-owned center or
satellite clinic or by physicians who belong to a specially formed medical group
that serves the HMO
closed-panel HMO
A managed care organization (MCO) is responsible for the health of a group of
__________ and can be a health plan, hospital, physician group, or health system
Enrollees
Which consumer-directed health plan allows tax-exempt accounts to be offered
by employers with 50 or more employees, which individuals then use to pay
health care bills? Funds must be used for qualified health care expenses, and
unspent money can be accumulated for future years. If an employee changes
jobs, he or she can continue to use the funds to pay for qualified health care
expenses
health reimbursement arrangement
An integrated delivery system (IDS) is an organization of __________ that offer
joint health care services to subscribers
affiliated providers' sites
Which consumer-directed health plan allows participants to enroll in a relatively
inexpensive high-deductible insurance plan and open a tax-deductible savings
account to cover current and future medical expenses? Money deposited (and
earnings) is taxdeferred, and money withdrawn to cover qualified medical
expenses is tax-free. Money can be withdrawn for purposes other than health
care expenses after payment of income tax plus a 15 percent penalty. Unused
balances "roll over" from year to year, and if an employee changes jobs, he or
she can continue to use the fund to pay for qualified health care expenses
health savings account
A health maintenance organization (HMO) is an alternative to traditional group
health insurance coverage and provides comprehensive health care services to
voluntarily enrolled members on a __________ basis
Prepaid
With managed care's capitation financing method, if the physician provides
services that cost less than the capitation amount, there is a profit, which the
physician
keeps to reinvest in the medical practice
Accreditation organizations develop standards that are reviewed during an
evaluation process that is conducted both offsite and onsite. The evaluation
process is called a(n)
Survey
Some managed care plans contract out utilization management services to a
utilization review organization (URO), which is an entity that
establishes a utilization management program and performs external utilization review
services
A managed care network of physicians and hospitals that have joined together to
contract with insurance companies, employers, or other organizations to provide
health care to subscribers for a discounted fee is called a(n)
preferred provider organization
, A management service organization (MSO) is usually owned by physicians or a
hospital and provides practice management (administrative and support) services
to
individual physician practices
Medicare established the Quality Improvement System for Managed Care (QISMC)
to ensure the accountability of managed care plans in terms of objective,
measurable
Standards
Many states have enacted legislation requiring a(n) __________ to review health
care provided by managed care organizations
external quality review organization
Which consumer-directed health plan funds health care expenses with insurance
coverage and the individual selects one of each type of provider to create a
customized network and pays the resulting customized insurance premium
customized sub-capitation plan
The National Committee for Quality Assurance (NCQA) reviews managed care
plans and develops report cards to
allow health care consumers to make informed decisions when selecting a plan
Which is a private, not-for-profit organization that assesses the quality of
managed care plans in the United States and releases the data to the public for
consideration when selecting a managed care plan
National Committee for Quality Assurance
The Healthcare Effectiveness Data and Information Set (HEDIS) was developed by
the __________ and created standards to assess managed care systems in terms
of membership, utilization of services, quality, access, health plan management
and activities, and financial indicators
National Committee for Quality Assurance (NCQA)
Which is associated with contracted health care services that are delivered to
subscribers by individual physicians in the community
direct contract model HMO
Which is associated with health care that is provided by individuals who are not
employees of the HMO or who do not belong to a specially formed medical group
that serves the HMO
open-panel HMO
Which is a method of controlling health care costs and quality of care by
reviewing the appropriateness and necessity of care provided to patients prior to
the administration of care or after care has been provided
utilization management
A medical foundation is a nonprofit organization that contracts with and
__________ the clinical and business assets of physician practices
Acquires
Reviewing the appropriateness and necessity of care provided to patients prior to
the administration of care is called __________ review, and such review after care
has been provided is called __________ review
prospective; retrospective
solution
Triple option plans are intended to prevent the problem of covering members who
are sicker than the general population, which is called __________ selection
Adverse
A group practice without walls (GPWW) establishes a contract that allows
physicians to maintain their own offices and share services, such a
appointment scheduling and billing
Which is a review for medical necessity of inpatient care prior to the patient's
admission
preadmission certification
Which involves arranging appropriate health care services for the patient who is
being released from an inpatient hospitalization
discharge planning
Which is created when a number of people are grouped for insurance purposes
and the cost of health care coverage is determined by employees' health status,
age, sex, and occupation
risk pool
Which is usually offered either by a single insurance plan or as a joint venture
among two or more insurance payers and provides subscribers or employees
with a choice of HMO, PPO, or traditional health insurance plans
triple option plan
Which is a review that grants prior approval for reimbursement of a health care
service
Preauthorization
Which is associated with contracted health care services that are delivered to
subscribers by participating physicians who are members of an independent
multispecialty group practice
group model HMO
A triple option plan is also called a __________ or flexible benefit plan because of
the different benefit plans and extra coverage options provided through the
insurer or third-party administrator
cafeteria plan
Prior to scheduling elective surgery, managed care plans often require a
__________ during which another physician is asked to evaluate the necessity of
surgery and recommend the most economical, appropriate facility in which to
perform the surgery
second surgical opinion
Which program resulted from the Balanced Budget Act of 1997 (BBA) and
requires that quality assurance activities are performed to improve the
functioning of Medicare Advantage (Medicare Part C) organizations
quality assessment and performance improvement (QAPI)
,Which is associated with health care that is provided in an HMO-owned center or
satellite clinic or by physicians who belong to a specially formed medical group
that serves the HMO
closed-panel HMO
A managed care organization (MCO) is responsible for the health of a group of
__________ and can be a health plan, hospital, physician group, or health system
Enrollees
Which consumer-directed health plan allows tax-exempt accounts to be offered
by employers with 50 or more employees, which individuals then use to pay
health care bills? Funds must be used for qualified health care expenses, and
unspent money can be accumulated for future years. If an employee changes
jobs, he or she can continue to use the funds to pay for qualified health care
expenses
health reimbursement arrangement
An integrated delivery system (IDS) is an organization of __________ that offer
joint health care services to subscribers
affiliated providers' sites
Which consumer-directed health plan allows participants to enroll in a relatively
inexpensive high-deductible insurance plan and open a tax-deductible savings
account to cover current and future medical expenses? Money deposited (and
earnings) is taxdeferred, and money withdrawn to cover qualified medical
expenses is tax-free. Money can be withdrawn for purposes other than health
care expenses after payment of income tax plus a 15 percent penalty. Unused
balances "roll over" from year to year, and if an employee changes jobs, he or
she can continue to use the fund to pay for qualified health care expenses
health savings account
A health maintenance organization (HMO) is an alternative to traditional group
health insurance coverage and provides comprehensive health care services to
voluntarily enrolled members on a __________ basis
Prepaid
With managed care's capitation financing method, if the physician provides
services that cost less than the capitation amount, there is a profit, which the
physician
keeps to reinvest in the medical practice
Accreditation organizations develop standards that are reviewed during an
evaluation process that is conducted both offsite and onsite. The evaluation
process is called a(n)
Survey
Some managed care plans contract out utilization management services to a
utilization review organization (URO), which is an entity that
establishes a utilization management program and performs external utilization review
services
A managed care network of physicians and hospitals that have joined together to
contract with insurance companies, employers, or other organizations to provide
health care to subscribers for a discounted fee is called a(n)
preferred provider organization
, A management service organization (MSO) is usually owned by physicians or a
hospital and provides practice management (administrative and support) services
to
individual physician practices
Medicare established the Quality Improvement System for Managed Care (QISMC)
to ensure the accountability of managed care plans in terms of objective,
measurable
Standards
Many states have enacted legislation requiring a(n) __________ to review health
care provided by managed care organizations
external quality review organization
Which consumer-directed health plan funds health care expenses with insurance
coverage and the individual selects one of each type of provider to create a
customized network and pays the resulting customized insurance premium
customized sub-capitation plan
The National Committee for Quality Assurance (NCQA) reviews managed care
plans and develops report cards to
allow health care consumers to make informed decisions when selecting a plan
Which is a private, not-for-profit organization that assesses the quality of
managed care plans in the United States and releases the data to the public for
consideration when selecting a managed care plan
National Committee for Quality Assurance
The Healthcare Effectiveness Data and Information Set (HEDIS) was developed by
the __________ and created standards to assess managed care systems in terms
of membership, utilization of services, quality, access, health plan management
and activities, and financial indicators
National Committee for Quality Assurance (NCQA)
Which is associated with contracted health care services that are delivered to
subscribers by individual physicians in the community
direct contract model HMO
Which is associated with health care that is provided by individuals who are not
employees of the HMO or who do not belong to a specially formed medical group
that serves the HMO
open-panel HMO
Which is a method of controlling health care costs and quality of care by
reviewing the appropriateness and necessity of care provided to patients prior to
the administration of care or after care has been provided
utilization management
A medical foundation is a nonprofit organization that contracts with and
__________ the clinical and business assets of physician practices
Acquires
Reviewing the appropriateness and necessity of care provided to patients prior to
the administration of care is called __________ review, and such review after care
has been provided is called __________ review
prospective; retrospective
