Medicaid plans provide for low-income families. Which statement regarding Medicaid is NOT correct?
All Medicaid plans offer HMO options.
Managed Care Organizations (MCOs) place the physician at financial risk for the care of the patient. How are they reimbursed?
Capitation
Dr. Williams is enrolled in a capitated plan. For his list of covered lives, he received a check for $100,000. During the year, the cost of treating the covered lives was $125,000. Which statement below is TRUE?
Dr. Williams has a loss of $25,000 on the capitated contract for the year.
A group contracts with a third-party administrator to manage paperwork. This group pays for the operation of the insurance plan and the costs of administration. What type of plan does this represent?
Self-Funded ERISA
Who does Medicare provide hospital coverage and voluntary medical insurance to?
a. Certain individuals of low-income
b. Persons aged 65 or older
c. Certain disabled individuals under age 65
X d. Both b and c are correct
A healthcare organization with 2 hospitals, 20 clinics, and 3 urgent care centers belongs to an ACO program. They have been in the shared savings program for two years and are now eligible to move large payments to a population-based model as they have been successful in keeping costs down and have met all the CMS benchmarks set for them. What type of ACO is this?
Pioneer ACO Model
What is the largest health program in the United States?
Medicare
Insurance coverage provided by an organization that is not an employer (such as a membership organization or credit card company that offers benefits to its members) is what kind of group insurance?
Association Group
What is the benefit of using NPI numbers for payers?
I. It is a single identifier for all payers
II. It contains the providers’ birthdates to allow certain identification
III. Each payer can make their own number
IV. It has no personal identifying information in the number
I, IV
NPI numbers have two types of entities. What are the two types:
Sole proprietor and Group
A patient is age 65 and Medicare eligible. The patient signs up for a Medicare Managed Care plan. When the patient presents for care, where are claims sent?
The Managed Care Plan
What is an IPO in a health organization?
corporate umbrella for management of diversified healthcare delivery systems
What are the 2022 Medicare deductible and co-insurance amounts for outpatient services on Part B?
$233 per calendar year and 20% of the approved amount
When a patient is enrolled in an HMO, which options below are the responsibilities of the primary care physician (PCP)?
I. Manage the member’s treatment
II. Be the only provider for all of the patient’s healthcare
III. Provide referrals to specialists
IV. Approve emergency department visits
V. Provide referrals for inpatient admissions
I, III, V
Medicare has 4 parts – which part is responsible for paying hospital claims?
Part A
A patient presents to his internist for a visit. The patient has a Medicare HMO. To which part of the Medicare program does the patient belong?
Part C
A patient needs to see a specialist for a cardiac condition. She references her insurance handbook for a list of network providers that belong to that specialty. She may choose any physician she wishes and does not need a referral from her Internist to see the specialist. If she chooses an out-of-network physician, she will have to pay a higher co-insurance amount to see them. What type of insurance does this patient have?
PPO
The following is a capitation schedule for a pediatric practice.
Member's Age Capitation per Member, per Month
0-1 $25.00
2-4 $10.00
5-20 $5.00
The practice has 300 members age 0-1, 500 members age 2-4, and 2000 members age 5-20 that stay with the practice for an entire year. If the practice also performs “carve-out” services worth $20,000, how much money will they earn over the course of a year?
$290,000
A patient presents for an immunization. When the patient pays his bill, he asks for a receipt so that he may turn it in to meet his spenddown. What type of coverage does this patient have?
Medicaid
Which of the following is NOT evaluated in the credentialing process?
Physician's request for privileges
The Protecting Patients and Affordable Care Act (PPACA) is a federal mandate which establishes that coverage can no longer be denied for what reason?
Pre-existing conditions
A Medicare patient is seen in the Internist’s office for a check-up. The office bills Medicare, but the patient receives the payment and the office must collect their fee from the patient. The office, by state law, can charge the patient a limiting charge that is 10 percent above the Medicare fee schedule amount. What type of Medicare provider is this physician?
Opt out
What are some of the ways that managed care organizations (MCOs) offer provisions that provide insurers with ways to manage the cost, use, and quality of healthcare services received by a member?
I. Utilization review
II. Coverage restrictions
III. Arbitration
IV. Non-emergency weekend admission restrictions
I, IV Utilization review and non-emergency weekend admission restrictions
An employee has signed up for a program through her employer. It allows her to put pre-tax money away from her paycheck in order to pay for out-of-pocket healthcare expenses. She may contribute up to $2850 (2022) per year. If she does not use all of the money during the current year, she forfeits it. What is this?
FSA
What does the acronym CHIP stand for?
Children’s Health Insurance Program