hfma cspr course 1 managed care overview comprehen
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HFMA CSPR
Course 1
Comprehensive
Final Exam Review
Q&A
2024
,1. What is the primary goal of managed care?
a) To provide unlimited healthcare services
b) To manage the cost of healthcare
c) To centralize healthcare services
d) To deregulate the healthcare industry
Answer: b) To manage the cost of healthcare
Rationale: Managed care aims to control healthcare costs while
maintaining quality of care through various mechanisms such as network
selection, negotiated rates, and utilization review.
2. Which of the following is a key feature of Health Maintenance
Organizations (HMOs)?
a) Fee-for-service payment model
b) Out-of-network coverage
c) Gatekeeper model for specialist services
d) High-deductible health plans
Answer: c) Gatekeeper model for specialist services
Rationale: HMOs typically require a primary care physician to act as a
gatekeeper to specialist services, which helps to control costs and ensure
coordinated care.
3. What does capitation payment involve?
a) Providers are paid for each service rendered
b) Providers are paid a set amount for each enrolled person assigned to
them
c) Patients pay out-of-pocket for all healthcare services
d) Providers receive bonuses for high patient satisfaction scores
Answer: b) Providers are paid a set amount for each enrolled person
assigned to them
Rationale: Capitation is a payment arrangement where providers are
paid a set fee per patient regardless of how many services the patient uses,
incentivizing efficient care delivery.
4. Which entity is primarily responsible for accrediting managed care
organizations?
a) The Centers for Medicare & Medicaid Services (CMS)
b) The National Committee for Quality Assurance (NCQA)
c) The Joint Commission
, d) The American Medical Association (AMA)
Answer: b) The National Committee for Quality Assurance (NCQA)
Rationale: NCQA is a non-profit organization that assesses and accredits
managed care organizations based on rigorous quality standards.
5. What is the purpose of utilization management in managed care?
a) To provide patients with unlimited access to specialists
b) To ensure that healthcare services are appropriate and medically
necessary
c) To increase healthcare costs
d) To limit patient choice in healthcare providers
Answer: b) To ensure that healthcare services are appropriate and
medically necessary
Rationale: Utilization management is a set of techniques used to manage
healthcare costs by reviewing the necessity and efficiency of services
provided.
6. Preferred Provider Organizations (PPOs) differ from HMOs in which
way?
a) PPOs do not require referrals for specialists
b) PPOs have a gatekeeper model
c) PPOs offer lower reimbursement rates to providers
d) PPOs only cover in-network services
Answer: a) PPOs do not require referrals for specialists
Rationale: PPOs provide more flexibility than HMOs, allowing
members to see specialists without a referral, though at a higher cost for
out-of-network services.
7. What is the role of a primary care physician (PCP) in a managed care
setting?
a) To provide specialist care services
b) To coordinate patient care and provide referrals when necessary
c) To handle administrative tasks for the managed care organization
d) To determine the reimbursement rates for services
Answer: b) To coordinate patient care and provide referrals when
necessary
Rationale: PCPs serve as the first point of contact in the healthcare
system and are responsible for coordinating patient care within the
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