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The administrative simplification standards described under Title II of HIPAA include privacy standards to control the use and disclosure of health information. In general, these privacy standards prohibit
The Fairway Health Group contracted with the Empire Corporation to provide behavioral healthcare services to Empire employees. As a condition of providing behavioral healthcare services, Fairway required Empire to contract with Fairway for basic medical s
The following statements describe common types of physician/hospital integrated models:
The Iota Company, which is owned by a group of investors, is a for-profit legal entity that buys entire physician practices, not just the tangible assets of the practice
Janet Riva is covered by a indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan. She incurred
Parul Gupta has been covered by a group health plan for eighteen months. For the past four months, she has been undergoing treatment for diabetes. Last week, Ms. Gupta began a new job and immediately enrolled in her new company's group health plan, which
The Clover Group is a for-profit MCO that operates in the United States. The Valentine Group owns all of Clover's stock. The Valentine Group's sole business is the ownership of controlling interests in the shares of other companies. This information indic
The following organizations are the primary sources of accreditation of healthcare organizations:
The Courtland PPO maintains computerized records that include clinical, demographic, and administrative data about individual plan members. The data in these records is available to plan providers, ancillary service departments, pharmacies, and others inv
John Kerry's employer has contracted to receive healthcare for its employees from the Democratic Healthcare System. Mr. Kerry visits his PCP, who sends him to have some blood tests. The PCP then refers Mr. Kerry to a specialist who hospitalizes him for on
Medicaid is a jointly funded federal and state program that provides hospital and medical expense coverage to low-income individuals and certain aged and disabled individuals. One characteristic of Medicaid is that
The NAIC adopted the HMO Model Act in order to provide a system of ongoing regulatory monitoring of HMOs. All of the following statements are correct about the HMO Model Act EXCEPT that it:
Medigap policies were standardized into ten standard benefit pl ranging from A-J by the ____
The Koster Company plans to purchase a health plan for its employees from Intuitive HMO. Intuitive will administer the plan and will bear the responsibility of guaranteeing claim payments by paying all incurred covered benefits. Koster will pay for the he
Disease management is typically set up as a voluntary outreach and support program for plan members with certain _________ diseases
The following statements describe healthcare services delivered to health plan members by plan providers. Select the statement that describes a service that would most likely require utilization review and authorization.
The Oriole MCO uses a typical diagnosis-related groups (DRGs) payment method to reimburse the Isle Hospital for its treatment of Oriole members. Under the DRG payment method, whenever an Oriole member is hospitalized at Isle, Oriole pays Isle
The following statements are about federal laws that affect healthcare organizations. Select the answer choice containing the correct response.
Select the correct statement regarding TRICARE Extra plan options to military personnel’s.
The following statements pertain to the federal requirements for minimum deductible & maximum out of pocket expeses for a high deductible health plan in the year 2006. Select the correct answer from the options given below.
The process that Mr. Sybex used to identify and classify the risk represented by the Koster Group so that Intuitive can charge premiums that are adequate to cover its expected costs is known as
Types of alternative care centers include urgent care centers, observation care units, and stepdown units. One difference between the costs associated with alternative care centers is that, compared to the cost of:
Wellborne HMO provides health-related information to its plan members through an Internet Web site. Laura Knight, a Wellborne plan member, visited Wellborne's Web site to gather uptodate information about the risks and benefits of various treatment option
The nature of the claims function within health plans varies by type of plan and by the compensation arrangement that the plan has made with its providers. For example, it is generally correct to say that, in a
When determining physicians' fee reimbursements, the Blossom Managed Healthcare Group assigns a weighted value to each medical procedure or service and multiplies the weighted value by a money multiplier, as shown below:
Weighted value for service × Money
The following statements apply to flexible spending arrangements. Select the answer choice that contains the correct statement.
The Blaine Healthcare Corporation seeks to manage its quality by first identifying the best practices and best outcomes for a given procedure. Blaine can then determine areas in which it can emulate the best practices in order to equal or surpass the best
Primary care case managers (PCCMs) provide managed healthcare services to eligible Medicaid recipients. With regard to PCCMs, it is correct to say that
Patrick Flaherty's employer has contracted to receive healthcare for its employees from the Abundant Healthcare System. Mr. Flaherty visits his primary care physician (PCP), who sends him to have some blood tests. The PCP then refers Mr. Flaherty to a special
One of the distinguishing characteristics of healthcare marketing is that many of the markets for health plans are national, not local markets.
One of the most influential pieces of legislation in the advancement of health plans within the United States was the Health Maintenance Organization (HMO) Act of 1973. One of the provisions of the Act was that it
As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members:
As part of its utilization management (UM) system, the Creole Health Plan uses a process known as case management. The following individuals are members of the Creole Health Plan:
The following statements describe two types, or models, of HMOs:
The Quest HMO has contracted with only one multi-specialty group of physicians. These physicians are employees of the group practice, have an equity interest in the practice, and provide
According to the IRS, which of the following is not an allowable preventive care service?
As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor's practices or services are better than its own, Lyric im
In most cases, medical errors are caused by breakdowns in the healthcare system rather than by provider mistakes.
A particular health plan offers a higher level of benefits for services provided in-network than for out-of-network services. This health plan requires preauthorization for certain medical services.
With regard to the steps that the health plan's claims e
An HMO that combines characteristics of two or more HMO models is sometimes referred to as a
A public employer, such as a municipality or county government would be considered which of the following?
Federal legislation has placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level.
This federal legislation is the
Col. Martin Avery, on active duty in the U.S. Army, is eligible to receive healthcare benefits under one of the three TRICARE health plan options. If Col Avery elects to participate in TRICARE Prime, he will be
For this question, select the answer choice containing the terms that correctly complete the blanks labeled A and B in the paragraph below.
NCQA offers Quality Compass, a national database of performance and accreditation information submitted by managed
In claims administration terminology, a claims investigation is correctly defined as the process of
In large health plans, management functions such as provider recruiting, credentialing, contracting, provider service, and performance management for providers are typically the responsibility of the
Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:
Dr. Milton Ware, a physician in the Riverside MCO's network of providers, is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members. Dr. Ware's provider contract with Riverside contains a typical no-balance billi
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence
TESTED 06 May 2024