CMSM Managed Care and Insurance Operations

Question 1

What is a Health Maintenance Organization (HMO)?

Accepted Answer

A managed care plan requiring members to use network providers and a primary care physician gatekeeper

Answer

A fee-for-service plan with no network restrictions

Answer

A plan that pays a percentage of all healthcare costs regardless of provider

Answer

A government-funded insurance program for elderly patients

Question 2

What does 'capitation' mean in managed care?

Accepted Answer

A fixed monthly payment per enrolled member regardless of services used

Answer

A limit on the number of patients a physician can see per day

Answer

A cap on the total annual benefits an insurance plan will pay

Answer

A penalty charged when members use out-of-network providers

Question 3

What is a Preferred Provider Organization (PPO)?

Accepted Answer

A managed care plan that allows members to use out-of-network providers at a higher cost

Answer

A plan that only covers preventive care services

Answer

A managed care plan with a restricted network and no out-of-network benefits

Answer

A government-sponsored health plan for low-income individuals

Question 4

What is the primary purpose of a Utilization Review (UR) process?

Accepted Answer

To assess the medical necessity and appropriateness of healthcare services

Answer

To evaluate employee performance and productivity

Answer

To review patient satisfaction surveys

Answer

To audit financial statements for accuracy

Question 5

Which term describes the process by which a patient must obtain permission from their insurance plan before receiving certain services?

Accepted Answer

Prior authorization

Answer

Concurrent review

Answer

Retrospective review

Answer

Claims adjudication

Question 6

What is a 'deductible' in health insurance?

Accepted Answer

The amount a patient must pay out-of-pocket before insurance begins covering costs

Answer

The maximum amount an insurance plan will pay in a year

Answer

The fixed amount a patient pays for each office visit

Answer

The monthly premium paid to maintain insurance coverage

Question 7

What does 'coordination of benefits' (COB) mean in health insurance?

Accepted Answer

A process to determine which insurance plan pays first when a patient has multiple coverages

Answer

Coordinating care between multiple healthcare providers

Answer

The process of scheduling patient appointments across departments

Answer

Managing the benefits package offered to employees