Managed Care Test #918

	Answer each of the following questions (there is only one correct answer to each question).
	1	The stimulus that inspired managed care was:
		A. federal legislation
		B. soaring medical costs
		C. a decline in hospital admissions
		D. President Clinton's proposed health insurance plan
	2	Before managed care most insurance plans were:
		A. paid for by the subscriber
		B. federally funded
		C. provider-sponsored organizations
		D. indemnity, or fee-for-service
	3	Case management is:
		A. a synonym for managed care
		B. the precursor of managed care
		C. a synonym for HMO
		D. one method for achieving managed care
	4	The health plan that is responsible for both the financing and delivery of health services is:
		A. PPO
		B. EPO
		C. HMO
		D. PSO
	5	The health plan that allows subscribers choices by coordinating care through a network of providers is called:
		A. PPO
		B. IPA
		C. HMO
		D. PCP
	6	In the staff model type of health maintenance organization:
		A. the physicians are HMO employees
		B. the HMO contracts with a medical group
		C. the HMO constructs a network of providers
		D. the employer contracts directly with individual physicians
	7	A network of health care providers who agree to discounted rates is:
		A. a PPO
		B. an IPA
		C. a group model HMO
		D. a staff model HMO
	8	If Mary Jones requires a mastectomy for treatment of her breast cancer, and she has a staff model HMO plan, she will probably:
		A. choose a surgeon and hospital from the members directory of providers
		B. go to an HMO hospital and use an HMO-employed surgeon
		C. choose any surgeon and hospital she wants as long as she pays her deductible and co-payment
		D. none of the above
	9	Susan Jones is a 33-year old computer programmer for a major airline. She was struck by a slow-moving automobile while jogging near her home. The paramedics transported her to the nearest hospital where she was diagnosed with fractures of her right tibia and fibula, plus numerous lacerations and abrasions. She will need surgical repair of her leg. Her health insurance plan is a PPO and the hospital is not a member of the PPO network. Will this hospital be allowed to admit and treat Susan?
		A. No, because they are not a member of Susan's preferred provider network
		B. Yes, if the hospital calls for authorization from the PPO
		C. Yes, if that is what Susan wants. She may get a better price for care if the hospital is part of her PPO network, but she will not be denied care when they are out-of-network
		D. No, since it is not a life-threatening emergency
	10	The health plan that bypasses the middleman (insurance carrier) is:
		A. PPO
		B. EPO
		C. HMO
		D. PSO
	11	Hospitals may be paid an all-inclusive amount for each day the patient is hospitalized. This type of rate is called:
		A. indemnity
		B. DRG
		C. per diem
		D. cost plus
	12	Which of the following is NOT a function of managed care:
		A. shorten lengths of stay
		B. decrease costs
		C. use only contracted providers
		D. limit dollars spent per subscriber per year
	13	Advantages of managed care include:
		A. coordinated care
		B. lack of paperwork
		C. phone access
		D. all of the above
	14	When figuring reimbursement based on costs and charges, it is important to remember:
		A. costs and charges are the same thing
		B. costs are discounted rates
		C. costs are what the hospital spends; charges are what is billed
		D. charges are what the hospital spends; costs are what is billed
	15	Disadvantages of managed care include all of the following EXCEPT:
		A. difficulty in obtaining a referral
		B. excessive paperwork
		C. travel restrictions
		D. quality issues
	16	Whenever a plan denies, reduces, or terminates patient services, a letter is sent to the subscriber. In that letter will be:
		A. reasons for the decision
		B. instructions for the appeal process
		C. clues to possible clerical errors
		D. all of the above
	17	If Mary Jones feels she needs a mammogram, but her HMO said it is not necessary at this time, which of the following are valid options for her:
		A. wait until the HMO authorizes it
		B. contact the NCQA for grievance procedures
		C. change doctors
		D. obtain a mammogram at her own expense, then follow grievance procedure for possible reimbursement
	18	Medicare managed care supplements:
		A. must offer every benefit offered by Medicare, but may also include additional benefits.
		B. can be individualized as they choose
		C. have their benefits package determined by HCFA guidelines
		D. are exactly the same as Medicare, but more convenient
	19	When a patient is denied services, the primary care physician:
		A. has no options other than to not treat the patient
		B. may speak on behalf of the patient to overturn the denial
		C. should be changed
		D. should be sent an appeal letter by the subscriber
	20	A subscriber who has a grievance with the managed care plan has what options?
		A. pay for the care
		B. file an appeal
		C. consult an attorney
		D. all of the above
	21	A nurse considering a future position as a case manager for a managed care company needs to know all of the following EXCEPT
		A. all work may be done by telephone without actually seeing a patient
		B. there is an excellent opportunity to educate providers and patients on the rules and regulations governing their care
		C. Medicare patients will not be a part of the patient group
		D. there is not one plan per company, but rather dozens of variations of plans within a particular company
	22	Medicare recipients choosing the "risk" type of managed care plan:
		A. are eligible to enroll only at the time of their 65th birthday
		B. have a choice of in-network or out-of-network providers
		C. must end enrollment with a signed request if they want to resume standard Medicare coverage
		D. are usually those who smoke, drink or indulge in other health-risk behavior
	23	The organization which rates HMOs is called the
		A. NCQA
		B. URAC
		C. CHMO
		D. HMOA
	24	Clinical pathways are also known by all the following terms EXCEPT
		A. care maps
		B. IPCs
		C. ARPs
		D. CCCs
	25	Clinical pathways include which major components?
		A. all care received by the patient
		B. physician treatment only
		C. nursing treatment only
		D. ancillary departments treatment only
	26	Managed care impacts which hospital nurses?
		A. utilization management only
		B. middle-and-upper level management nurses only
		C. all hospital nurses
		D. primarily admissions nurses and discharge planners
	27	When Mary Jones has her mastectomy, the critical pathway will help the nurses caring for her to:
		A. match her progress to specific clinical indicators
		B. hold costs down below the set spending limit
		C. have her ready for discharge at the pre-determined time
		D. get their work done more quickly
	28	Which of the following nurses are involved in managed care? utilization management nurses admissions nurses discharge planning nurses staff nurses quality management nurses office nurses clinic nurses home health nurses
		A. 1, 2, 3, and 4 only
		B. 1, 2, and 5 only
		C. 6, 7, and 8 only
		D. 1, 2, 3, 4, 5, 6, 7, and 8
	29	When is a managed care patient discharged from an acute hospital?
		A. when the length of stay for that diagnosis has been reached
		B. when the managed care review nurse determines is appropriate
		C. when the hospital utilization nurse determines the patient is ready
		D. when the attending physician determines there is no longer medical necessity for acute inpatient care
	30	Futurists looking at managed care say they predict:
		A. no change in the current system
		B. a total elimination of the current system
		C. introduction of DRGs into the workplace
		D. plans will be more competitive, therefore they will be forced to offer increased quality of care.
	Remember to click "Submit" ONCE and please be patient while your answers are checked and the results are displayed. You will then be returned to this page to complete the required Evaluation. (Click on Evaluation when returning to this page.) Thank you for choosing the National Center!