Cortiva Institute Pennsylvania National Committee for Quality Assurance Questions

2. Which coding system is used to report procedures and services on claims?

3. The Healthcare Common Procedure Coding System (HCPCS) consists of __________ codes.

4. Which coding system is used to report procedures and services on inpatient hospital claims?

5. Which are published by CMS and used to report procedures, services, and supplies not classified in CPT?

1. Managed health care was developed as a way to provide affordable, comprehensive, prepaid health care services to __________.

2. The Healthcare Effectiveness Data and Information Set (HEDIS) was developed by the __________ and created standards to assess managed care systems in terms of membership, utilization of services, quality, access, health plan management and activities, and financial indicators.

3. A managed care organization (MCO) is responsible for the health of a group of __________ and can be a health plan, hospital, physician group, or health system.

4. With managed care’s capitation financing method, if the physician provides services that cost less than the capitation amount, there is a profit, which the physician ___________.

5. The primary care provider (PCP) is responsible for __________.

6. Managed care plans that are “federally qualified” and those that must comply with state quality review mandates, or __________, are required to establish quality assurance programs.

7. A quality assurance program includes activities that __________ the quality of care provided in a health care setting.

8. Many states have enacted legislation requiring a(n) __________ to review health care provided by managed care organizations.

9. The National Committee for Quality Assurance (NCQA) reviews managed care plans and develops report cards to __________.

10. Which is a method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care or after care has been provided?

11. Reviewing the appropriateness and necessity of care provided to patients prior to the administration of care is called __________ review, and such review after care has been provided is called __________ review.

12. Which is a review for medical necessity of inpatient care prior to the patient’s admission?

13. Which is a review that grants prior approval for reimbursement of a health care service?

14. Which is a review for medical necessity of tests and procedures ordered during an inpatient hospitalization?

15. Which involves arranging appropriate health care services for the patient who is being released from an inpatient hospitalization?

16. Some managed care plans contract out utilization management services to a utilization review organization (URO), which is an entity that __________.

17. Which involves the development of patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner?

18. Prior to scheduling elective surgery, managed care plans often require a __________ during which another physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery.

19. Medicare and many states prohibit managed care contracts from containing __________, which prevent providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.

20. Physician incentives include payments made directly or indirectly to health care providers to __________ so as to save money for the managed care plan. Managed care plans that contract with Medicare or Medicaid must disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval.

21. An integrated delivery system (IDS) is an organization of __________ that offer joint health care services to subscribers.

22. A physician-hospital organization (PHO) is owned by hospital(s) and physician groups that obtain managed care plan contracts. The physicians __________ and provide health care services to plan members.

23. A management service organization (MSO) is usually owned by physicians or a hospital and provides practice management (administrative and support) services to __________.

24. A group practice without walls (GPWW) establishes a contract that allows physicians to maintain their own offices and share services, such as __________.

25. An integrated provider organization (IPO) manages the delivery of health care services offered by hospitals, physicians, and other health care organizations. Physicians associated with an IPO are considered __________.

26. A medical foundation is a nonprofit organization that contracts with and __________ the clinical and business assets of physician practices.

27. A health maintenance organization (HMO) is an alternative to traditional group health insurance coverage and provides comprehensive health care services to voluntarily enrolled members on a __________ basis.

28. Which is associated with health care that is provided in an HMO-owned center or satellite clinic or by physicians who belong to a specially formed medical group that serves the HMO?

29. Which is associated with health care that is provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO?

30. Which is associated with contracted health care services that are delivered to subscribers by participating physicians who are members of an independent multispecialty group practice?

31. Health care services provided to subscribers by physicians employed by the HMO are associated with a __________. Premiums and other revenue are paid to the HMO, and usually all ambulatory services are provided within HMO corporate buildings.

32. Which is associated with contracted health care services that are delivered to subscribers by individual physicians in the community?

33. Which is associated with contracted health care services that are provided to subscribers by two or more physician multispecialty group practices?

34. Which type of HMO contracts health services that are delivered to subscribers by physicians who remain in their own office settings?

35. To create flexibility in managed care plans, some HMOs and preferred provider organizations have implemented a(n) __________, under which patients have freedom to use the managed care panel of providers or to self-refer to out-of-network providers.

36. A managed care network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee is called a(n) __________.

37. Which is created when a number of people are grouped for insurance purposes and the cost of health care coverage is determined by employees’ health status, age, sex, and occupation?

38. Which is a private, not-for-profit organization that assesses the quality of managed care plans in the United States and releases the data to the public for consideration when selecting a managed care plan?

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