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
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller keithdaniel. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $24.99. You're not tied to anything after your purchase.
