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

HMOs require members to select a primary care physician and use network providers, with the PCP acting as a gatekeeper for specialist referrals.

Question 2

What does 'capitation' mean in managed care?

Accepted Answer

A fixed monthly payment per enrolled member regardless of services used

Answer

Capitation is a payment model where providers receive a fixed per-member-per-month payment regardless of how many services are actually provided.

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

PPOs allow members to visit any provider but offer lower cost-sharing when using in-network (preferred) providers, making out-of-network care available at higher out-of-pocket cost.

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

Utilization review evaluates whether healthcare services are medically necessary, appropriate, and delivered in the most cost-effective setting.

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

Prior authorization (preauthorization) requires patients or providers to get approval from the insurance plan before certain services or medications are provided.

CMSM - Certified Medical Services Manager Practice Test

CMSM - Certified Medical Services Manager Practice Test

CMSM Managed Care and Insurance Operations