CMAA Healthcare Systems, Settings, and the Healthcare Team — Questions and Answers
Question 1: Which type of health insurance plan requires patients to select a primary care physician (PCP) who must provide referrals before the patient can see a specialist?
- Preferred Provider Organization (PPO)
- Health Maintenance Organization (HMO) (Correct answer)
- High-Deductible Health Plan (HDHP)
- Fee-for-Service (Indemnity) plan
Correct answer: Health Maintenance Organization (HMO)
HMO plans use a 'gatekeeper' model in which the designated PCP coordinates all care and must issue a referral before the insurer will cover specialist visits. PPOs allow direct access to specialists at a higher out-of-pocket cost, and indemnity plans impose no network restrictions.
Question 2: What is the primary purpose of accreditation by an organization such as The Joint Commission (TJC)?
- To set the fee schedule that providers may charge for services
- To license individual physicians to practice medicine in a state
- To evaluate healthcare organizations against quality and safety standards and certify compliance (Correct answer)
- To negotiate insurance contracts on behalf of hospital systems
Correct answer: To evaluate healthcare organizations against quality and safety standards and certify compliance
Accreditation bodies like The Joint Commission assess whether healthcare facilities meet established quality, safety, and operational standards. Accreditation is separate from licensure (a state function) and has no role in setting fees or negotiating insurance contracts.
Question 3: In a medical practice, which team member is primarily responsible for diagnosing conditions and ordering treatments?
- Medical administrative assistant
- Certified nursing assistant (CNA)
- Licensed physician or advanced practice provider (APP) (Correct answer)
- Medical billing specialist
Correct answer: Licensed physician or advanced practice provider (APP)
Diagnosing conditions and ordering treatments falls within the clinical scope of licensed physicians and advanced practice providers (nurse practitioners, physician assistants). Administrative and billing staff have separate, non-clinical roles.
Question 4: Which model of care delivery groups doctors, hospitals, and other providers together to coordinate care and share financial accountability for quality outcomes?
- Preferred Provider Organization (PPO)
- Accountable Care Organization (ACO) (Correct answer)
- Health Reimbursement Arrangement (HRA)
- Exclusive Provider Organization (EPO)
Correct answer: Accountable Care Organization (ACO)
An ACO is a network of providers who voluntarily coordinate patient care and share in savings (or losses) tied to quality metrics and cost targets, primarily under Medicare programs. This distinguishes it from PPOs and EPOs, which are insurance network structures.
Question 5: A medical administrative assistant verifying that a newly hired physician's education, training, and licensure meet the required standards is performing which process?
- Onboarding
- Privileging
- Credentialing (Correct answer)
- Performance review
Correct answer: Credentialing
Credentialing is the formal process of collecting and verifying a provider's qualifications — including degrees, training programs, board certifications, and licenses — before they are authorized to practice at a facility or be enrolled with payers. Privileging is a related but distinct step that grants specific clinical permissions after credentialing is complete.
Question 6: Which of the following best describes a 'solo practice' in a medical office context?
- A practice owned by a hospital system where all physicians are hospital employees
- A practice in which one physician owns and operates the office independently (Correct answer)
- A practice with multiple physicians sharing profits under a group partnership
- A federally qualified health center serving underserved communities
Correct answer: A practice in which one physician owns and operates the office independently
A solo practice is owned and operated by a single physician who bears full financial and legal responsibility for the business. This is distinct from group practices (multiple physician-owners), hospital-based practices (hospital employs the physicians), and FQHCs (federally funded community health centers).
CMAA Healthcare Systems, Settings, and the Healthcare Team
Which type of health insurance plan requires patients to select a primary care physician (PCP) who must provide referrals before the patient can see a specialist?