FREE AND STUDY GAMES ABOUT LJLINDROSE61 EXAM

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FREE AND STUDY GAMES ABOUT LJLINDROSE61 EXAM

QUESTIONS

Actual Qs and Ans Expert-Verified Explanation

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-Guarantee passing score -33 Questions and Answers -format set of multiple-choice -Expert-Verified Explanation Question 1: Healthcare plan that encourages individuals to locate the best health care at the lowest possible price, with the goal of holding down costs; also called consumer-directed health plan.

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consumer-directed health plan (CDHP) Question 2: Requires managed care plans that contract with Medicare and Medicaid to disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval.

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physican incentive plan Question 3: Plan which reimburse providers for indiidual healthcare services rendered.

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fee-for-serviced plan

Question 4: Employees and dependents who join a managed care plan.

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enrollees Question 5: An entity that establishes a utilization management program and performs external utilization review services.

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utilization review organization (URO) Question 6: Reimbursement methodology that increases payment if the healthcare service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services.

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fee-for-service Question 7: Responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system.

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managed care organization (MCO) Question 8: Patients have freedom to use the managed panel of providers or to self-refer to non-managed care providers.

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point-of-service plans (POS) Question 9: Combines healthcare delivery with the financing of services provided.

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managed health care (managed care) Question 10: Method of controlling healthcare costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care.

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utilization management (utilization review)

Question 11: Reviewing appropriateness and necessity of care provided to patients after the administration of care.

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retrospective review Question 12: A second physician is asked to evaluate the necessity of elective surgery and recommend the most economical, appropriate facility in which to perform surgery.

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second surgical opinion (SSO)

Question 13: Managed care is currently being challenged by the growth of what?

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consumer-directed health plans (CDHPs)

Question 14: Person in whose name the insurance policy is issued.

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subscriber (policyholder) Question 15: Managed care plan that provides benefits to subscribers who are required to receive services from netowrk providers.

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exclusive provider organization (EPO) Question 16: An alternative to traditional grup health insurance coverage and provides comprehensive healthcare services to volulntarily enrolled members on a prepaid basis.

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health maintenance organization (HMO) Question 17: Voluntary process that a healthcare facility or organization undergoes to demonstrate that it has met standards beyond those required by law.

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accreditation

Question 18: Involves arranging appropriate healthcare services for the discharged patient (e.g., home health care).

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discharge planning Question 19: A private, not-for-profit organization that assesses the quality of managed care plans in the United States and releases data to the public for consideration when selecting a managed care plan.

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National Committee for Quality Assurance (NCQA) Question 20: Prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.

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gag clause Question 21: Review that grants prior approval for reimbursement of a healthcare service (e.g., elective surgery).

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preauthorization Question 22: Includes payments made directly or indirectly to healthcare providers to encourage them to reduce or limit services so as to save money for the managed care plan.

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physician incentives Question 23: Managed care organizations (MCOs) were created to manage benefits and to develop participating provider networks. Managed care can now be categorized according to six models.

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exclusive provider organization (EPO); integrated delivery system (IDS); health maintenance organization (HMO); point-of-service plan (POS); preferred provider organization (PPO); triple option plan