Managed Care: Ensuring Appropriate Healthcare Services while Controlling Costs, Exams of Nursing

Download Managed Care: Ensuring Appropriate Healthcare Services while Controlling Costs and more Exams Nursing in PDF only on Docsity! 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 1. What is the primary goal of managed care? A. To increase healthcare costs B. To provide comprehensive healthcare services while controlling costs C. To limit access to healthcare services D. To prioritize profit over patient care Answer: B. To provide comprehensive healthcare services while controlling costs Rationale: Managed care aims to provide high-quality healthcare services while managing costs and promoting cost-effective care delivery. 2. Which of the following is a common feature of managed care organizations? A. Unlimited access to specialists B. Limited provider networks C. Fee-for-service payment models D. No utilization management techniques Answer: B. Limited provider networks Rationale: Managed care organizations often have networks of providers with whom they have negotiated contracts to provide care to their members, leading to limited provider choices. 3. Which of the following is NOT a type of managed care organization? A. Health maintenance organization (HMO) B. Preferred provider organization (PPO) C. Fee-for-service plan D. Point of Service plan (POS) Answer: C. Fee-for-service plan Rationale: Fee-for-service plans are not considered managed care organizations as they do not typically involve managed care techniques to control costs. 4. What is the role of utilization management in managed care? A. To promote unnecessary healthcare services B. To limit access to necessary healthcare services C. To determine the medical necessity of services provided D. To prioritize profit over patient care Answer: C. To determine the medical necessity of services provided Rationale: Utilization management helps managed care organizations ensure that healthcare services are necessary and appropriate for the patient's condition, helping control costs. 5. Which type of managed care organization requires members to choose a primary care physician (PCP) to coordinate their care? A. Health maintenance organization (HMO) B. Preferred provider organization (PPO) C. Point of Service plan (POS) D. Exclusive provider organization (EPO) Answer: A. Health maintenance organization (HMO) Rationale: HMOs require members to choose a PCP who serves as a gatekeeper to coordinate their care and provide referrals to specialists when necessary. 6. How do managed care organizations control costs while providing comprehensive healthcare services? A. By eliminating access to necessary care B. By negotiating discounts with providers C. By encouraging unnecessary tests and procedures D. By prioritizing profit over patient care Answer: B. By negotiating discounts with providers Rationale: Managed care organizations negotiate discounts with providers in their network to control costs while still providing necessary healthcare services to their members. 7. Which of the following is a potential advantage of managed care? A. Encourages unnecessary healthcare services B. Increases healthcare costs C. Reduces out-of-pocket expenses for members D. Limits access to necessary care Answer: C. Reduces out-of-pocket expenses for members Rationale: Managed care can help reduce out-of-pocket expenses for members by negotiating lower prices with providers and coordinating care to prevent duplication of services. 8. Which managed care organization type offers the most flexibility in choosing healthcare providers? A. Health maintenance organization (HMO) B. Preferred provider organization (PPO) C. Point of Service plan (POS) D. Exclusive provider organization (EPO) Answer: B. Preferred provider organization (PPO) Rationale: PPOs allow members to choose providers both inside and outside the network, providing more flexibility in selecting healthcare providers. 9. What is the main focus of managed care organization's quality Answer: D. Limits access to necessary care Rationale: Some critics argue that managed care can limit access to necessary care by requiring referrals for specialist services and restricting provider choices. 15. How do managed care organizations promote cost-effective care delivery? A. By encouraging unnecessary tests and procedures B. By reducing provider reimbursements C. By incentivizing high-quality, cost-effective care D. By prioritizing profit over patient care Answer: C. By incentivizing high-quality, cost-effective care Rationale: Managed care organizations use various strategies such as pay- for-performance programs and utilization management techniques to incentivize providers to deliver high-quality, cost-effective care to their members. 16. Which of the following is a key characteristic of capitation payment models used in managed care? A. Paying providers based on the number of services provided B. Providing unlimited access to specialists C. Rewarding unnecessary tests and procedures D. Fixed payment per member to cover all healthcare services Answer: D. Fixed payment per member to cover all healthcare services Rationale: Capitation payment models involve paying providers a fixed amount per member per month to cover all necessary healthcare services, encouraging cost-effective care delivery. 17. What is the purpose of care coordination in managed care? A. To increase healthcare costs B. To improve patient outcomes C. To limit access to necessary care D. To prioritize profit over patient care Answer: B. To improve patient outcomes Rationale: Care coordination in managed care helps ensure that patients receive appropriate care, prevent duplication of services, and improve patient outcomes by coordinating care among different providers. 18. Which of the following best describes the concept of gatekeeping in managed care? A. Prohibiting access to necessary care B. Restricting provider choices C. Requiring referrals for specialist services D. Encouraging unnecessary tests and procedures Answer: C. Requiring referrals for specialist services Rationale: Gatekeeping in managed care involves requiring patients to obtain a referral from their primary care physician before seeing a specialist to control costs and ensure appropriate care. 19. Which type of managed care organization typically has the highest level of member cost-sharing? A. Health maintenance organization (HMO) B. Preferred provider organization (PPO) C. Point of Service plan (POS) D. Exclusive provider organization (EPO) Answer: A. Health maintenance organization (HMO) Rationale: HMOs typically have lower premiums but may require higher levels of cost-sharing, such as copayments or deductibles, for services outside the network. 20. How do managed care organizations ensure healthcare quality for their members? A. By reducing provider reimbursements B. By incentivizing high-quality, cost-effective care C. By limiting access to necessary care D. By prioritizing profit over patient care Answer: B. By incentivizing high-quality, cost-effective care Rationale: Managed care organizations use quality improvement programs, pay-for-performance initiatives, and utilization management techniques to incentivize providers to deliver high-quality, cost-effective care to their members. 21. Which of the following managed care organization types typically requires referrals for specialist services? A. Health maintenance organization (HMO) B. Preferred provider organization (PPO) C. Point of Service plan (POS) D. Exclusive provider organization (EPO) Answer: A. Health maintenance organization (HMO) Rationale: HMOs often require members to obtain referrals from their primary care physician for specialist services to control costs and ensure appropriate utilization of healthcare services. 22. Which of the following is NOT a way managed care organizations control costs? A. Negotiating discounts with providers B. Providing unlimited access to specialists C. Utilization management techniques D. Pay-for-performance programs Answer: B. Providing unlimited access to specialists A. Providing unlimited access to specialists B. Encouraging unnecessary tests and procedures C. Negotiating contracts with providers D. Limiting access to necessary care Answer: C. Negotiating contracts with providers Rationale: Network management in managed care involves negotiating contracts with providers to establish networks of healthcare professionals who deliver care to the organization's members, helping control costs and ensure quality of care. 29. How do managed care organizations address disparities in healthcare access and outcomes? A. By limiting access to necessary care B. By prioritizing profit over patient care C. By implementing quality improvement programs D. By encouraging unnecessary tests and procedures Answer: C. By implementing quality improvement programs Rationale: Managed care organizations often use quality improvement programs, care coordination, and population health initiatives to address disparities in healthcare access, improve outcomes, and promote equity in care delivery. 30. Which of the following is a potential challenge of managed care organizations' cost containment strategies? A. Reducing unnecessary tests and procedures B. Limiting access to necessary care C. Promoting high-quality care D. Encouraging preventive care services Answer: B. Limiting access to necessary care Rationale: Some critics argue that managed care organizations' cost containment strategies may lead to limitations in access to necessary care for patients, potentially impacting patient outcomes and satisfaction.\ Which of the following best describes managed care? A) A system that focuses solely on maximizing profits for healthcare providers B) A system that aims to control costs while maintaining quality care for patients C) A system that prioritizes unnecessary healthcare services for patients D) A system that disregards patient outcomes in favor of cost-cutting measures Answer: B) A system that aims to control costs while maintaining quality care for patients Rationale: Managed care is designed to strike a balance between cost containment and ensuring high-quality healthcare services for patients. What is the primary goal of managed care organizations? A) Maximizing healthcare costs B) Providing unlimited access to healthcare services C) Controlling healthcare costs and improving quality of care D) Ignoring patient needs in favor of financial gains Answer: C) Controlling healthcare costs and improving quality of care Rationale: Managed care organizations strive to manage costs effectively while enhancing the quality of healthcare services delivered to patients. Which of the following is a common feature of managed care plans? A) Unlimited coverage for all healthcare services B) Open-ended reimbursement for healthcare providers C) Utilization review to assess the necessity of healthcare services D) Non-negotiated contracts with healthcare providers Answer: C) Utilization review to assess the necessity of healthcare services Rationale: Utilization review is a key component of managed care plans, helping to determine the appropriateness and necessity of healthcare services provided to patients. What role does case management play in managed care? A) Minimizing patient access to necessary healthcare services B) Maximizing healthcare costs for patients C) Coordinating and managing care for patients efficiently D) Disregarding patient needs in treatment planning Answer: C) Coordinating and managing care for patients efficiently Rationale: Case management in managed care involves coordinating and managing the care of patients effectively to ensure optimal outcomes and cost-effective treatment. How do managed care organizations typically negotiate payment rates with healthcare providers? A) Through fixed-rate contracts B) By providing unlimited reimbursement C) By disregarding cost considerations D) Through open-ended payment agreements Answer: A) Through fixed-rate contracts Rationale: Managed care organizations often negotiate fixed-rate contracts with healthcare providers to control costs and streamline reimbursement processes. Which of the following is a key advantage of managed care for patients? A) Unlimited access to healthcare services B) Cost-effective care without compromising quality C) Uncertainty regarding covered services D) Lack of coordination in treatment planning Answer: B) Cost-effective care without compromising quality Rationale: Managed care aims to provide cost-effective healthcare services without compromising the quality of care delivered to patients. Answer: C) To assess the necessity and appropriateness of healthcare services Rationale: Utilization review is crucial in managed care to evaluate the necessity and appropriateness of healthcare services provided to patients. How do managed care organizations negotiate payment rates with healthcare providers? A) Through open-ended payment agreements B) By providing unlimited reimbursement C) Through fixed-rate contracts D) By disregarding cost considerations Answer: C) Through fixed-rate contracts Rationale: Managed care organizations often negotiate fixed-rate contracts with healthcare providers to establish clear payment terms and control costs. What is a significant advantage of managed care for patients? A) Uncertainty regarding covered services B) Lack of coordination in treatment planning C) Cost-effective care without compromising quality D) Unlimited access to healthcare services Answer: C) Cost-effective care without compromising quality Rationale: Managed care offers patients cost-effective healthcare services without compromising the quality of care delivered. What role does utilization review play in managed care plans? A) Limiting patient access to necessary healthcare services B) Ensuring the appropriateness and necessity of healthcare services C) Providing unlimited coverage for all medical treatments D) Disregarding patient outcomes in treatment planning Answer: B) Ensuring the appropriateness and necessity of healthcare services Rationale: Utilization review is essential in managed care plans to evaluate the appropriateness and necessity of healthcare services provided to patients. How do managed care organizations promote cost containment? A) By encouraging unnecessary medical procedures B) Through effective utilization management strategies C) By providing unlimited financial resources to healthcare providers D) By disregarding quality of care in favor of cost savings Answer: B) Through effective utilization management strategies Rationale: Managed care organizations focus on utilizing management strategies to contain costs while upholding the quality of care for patients. What purpose does contracting serve in managed care networks? A) Ensuring unlimited access to healthcare providers B) Negotiating reimbursement rates with no consideration for costs C) Establishing relationships with healthcare providers for network coverage D) Disregarding the need for provider networks Answer: C) Establishing relationships with healthcare providers for network coverage Rationale: Contracting in managed care networks involves building relationships with healthcare providers to create networks that offer coverage to patients. Which of the following is a common characteristic of managed care plans? A) Open-ended reimbursement for all healthcare services B) Limiting patient choice of healthcare providers C) Disregarding the quality of care provided to patients D) Providing unlimited financial resources to healthcare providers Answer: B) Limiting patient choice of healthcare providers Rationale: Managed care plans often restrict patient choice of healthcare providers to ensure efficient care delivery and cost containment. How do managed care organizations prioritize cost containment? A) By encouraging unnecessary medical procedures B) Through utilization management and cost-effective practices C) By providing unlimited financial resources to healthcare providers D) By disregarding quality of care in favor of cost savings Answer: B) Through utilization management and cost-effective practices Rationale: Managed care organizations prioritize cost containment through effective utilization management and cost-effective practices. What is a key benefit of case management in managed care? A) Increasing healthcare costs for patients B) Disregarding patient needs in treatment planning C) Coordinating and managing care for patients efficiently D) Minimizing patient access to necessary healthcare services Answer: C) Coordinating and managing care for patients efficiently Rationale: Case management in managed care plays a crucial role in efficiently coordinating and managing care for patients to achieve optimal outcomes. Why is utilization review important in managed care? A) To encourage unnecessary healthcare services B) To limit patient access to necessary treatments C) To assess the necessity and appropriateness of healthcare services D) To disregard patient outcomes in treatment planning Answer: C) To assess the necessity and appropriateness of healthcare services Rationale: Utilization review is vital in managed care to evaluate the necessity and appropriateness of healthcare services provided to patients. How do managed care organizations negotiate payment rates with healthcare providers? A) Through open-ended payment agreements B) By providing unlimited reimbursement C) Through fixed-rate contracts D) By disregarding cost considerations