What is the overall function of Medicaid? - CORRECT
ANSWER >>>>The pay for medical assistance for
certain individuals and low-income families
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR)
is defined as: - CORRECT ANSWER >>>>Total Medical
Expenses divided by Total Premiums
Provider service organizations (PSOs) function like
health maintenance organizations (HMOs) in all of the
following ways, EXCEPT: - CORRECT ANSWER >>>>Ties
to the healthcare delivery industry rather than the
insurance industry
,2|Page
Provider service organizations (PSOs) function like
health maintenance organizations (HMOs) in all of the
following ways: - CORRECT ANSWER >>>>-Risk pooling
-Capitalization
-Network management
Which of the following is a service provided by a well-
managed third-party administrator (TPA)? - CORRECT
ANSWER >>>>-Administrative
-Utilization review (UR)
-Claims processing
What is tiering? - CORRECT ANSWER >>>>The ranking
or classifying of one or more of the provider delivery
system components
Which option is a practice used to control costs of
managed care? - CORRECT ANSWER >>>>-Making
advance payment to providers for all services needed
to care for a member
-Combining services provided and bundling the
associated charges
-Agreement between the payer and provider on
reasonable payment for each service.
,3|Page
Which option is a risk involved in per diem payments?
- CORRECT ANSWER >>>>-The risk to the insurance
company or health plan
-The risk to the hospital
-The risk when embracing per diem payments in
complex case
Diagnosis-related group (DRG) is: - CORRECT ANSWER
>>>>A payment category
How is the term carve-out used when discussing
managed care? - CORRECT ANSWER >>>>To refer to
specific benefits or services
What is the term Coordination of Benefits (COB)? -
CORRECT ANSWER >>>>A term used to describe how
payment is coordinated for patients who have
coverage through two insurance policies
Which three components are used to determine the
total RVU value for a service? - CORRECT ANSWER
>>>>-Malpractice expense
-Lowest market price for services used
-Medicare discounts
, 4|Page
A fixed payment amount based upon the number of
members assigned to a provider, and does not vary
based upon the number of services rendered, is
known as: - CORRECT ANSWER >>>>Capitation
Aligning incentives has come to mean _________. -
CORRECT ANSWER >>>>The appropriate addition of
some risk in the exchange of health care to a patient
for some form of remuneration.
According to MedPAC, which option is a benefit or
undesirable consequence of bundling
payments? - CORRECT ANSWER >>>>-It allows
Medicare to pay a set fee per hospitalization episode.
-It would provide the potential to improve efficiency
and quality
-It would lead to underutilization of services
As the healthcare industry moves to control growth in
medical spending, what initiative can help hospitals
maintain their margins? - CORRECT ANSWER
>>>>Contract standardization
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