Healthcare Management: An Introduction
Last Update Oct 15, 2025
Total Questions : 367
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From the following choices, choose the definition that best matches the term Screening
In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known
Consumer-directed health plans are not a new concept. They actually got their start in the late 1970s with the advent of:
The following statements describe two types, or models, of HMOs:
The Quest HMO has contracted with only one multi-specialty group of physicians. These physicians are employees of the group practice, have an equity interest in the practice, and provide
From the following choices, choose the definition that best matches the term health risk assessment (HRA)
Dr. Milton Ware, a physician in the Riverside MCO's network of providers, is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members. Dr. Ware's provider contract with Riverside contains a typical no-balance billi
A public employer, such as a municipality or county government would be considered which of the following?
By definition, the marketing process of defining a certain place or market niche for a product relative to competitors and their products and then using the marketing mix to attract certain market segments is known as
An HMO that combines characteristics of two or more HMO models is sometimes referred to as a
If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info
Health plans use the following to determine the number of providers to add to a network:
By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an HMO provides comprehensive care include
Calculate the hospital bed days per 1000 members for the Month to date (MTD) on 25 April, with plan membership of 25,000 and total gross hospital bed days in MTD is 300 for an XYZ Health plan?
The main purpose of the Health Plan Employer Data and Information Set (HEDIS) is to provide
The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the difference between the hi
System classifies hundreds of hospital services based on a number of criteria, such as primary and secondary diagnosis, surgical procedures, age, gender, and the presence of complications.
Using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider is called ______________.
The following statements describe corporate transactions:
Transaction A – An MCO acquired another MCO.
Transaction B – A group of providers formed an organization to carry out billings, collections, and contracting with MCOs for the entire group of provide
The Meadowcreek Group is an organization comprised of individual physicians and physicians in small group practices. Meadowcreek enters into contracts with health plans, and then Meadowcreek contracts separately with its physician members. In situations w
Diabetic patients with high glucose levels requiring stabilization following treatment of an acute attack would best be served in an ___________
To achieve widespread use of electronic data interchange (EDI) in the healthcare industry, all entities within the industry need to agree on industry standards regarding the information format and software to be used. Several organizations are making cont
The Venus Hospital provides medical care to paying patients, as well as to people who either have no healthcare coverage and cannot pay for the care by themselves or who receive services at reduced rates because they are covered under government sponsored
To determine fee reimbursements to be paid to physicians, the Triangle Health Plan assigns a weighted value to each medical procedure or service and multiplies the weighted value by a money multiplier. Triangle and the providers negotiate the value of the
Which of the following statements about Family and Medical Leave Act (FMLA) is WRONG?
Types of alternative care centers include urgent care centers, observation care units, and stepdown units. One difference between the costs associated with alternative care centers is that, compared to the cost of:
The Madison Health Plan, a national MCO, and a local hospital system that operates its own managed healthcare network recently created a new and separate managed healthcare organization, the Pineapple Health Plan. Madison and the hospital system share own
In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice containing the two terms that you have chosen. For providers, (operational /
The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be
Some providers use electronic medical records (EMRs) to document their patients' care in an electronic form. The following statement(s) can correctly be made about EMRs:
The Cleopatra Group, a third-party administrator (TPA), has entered into a TPA agreement with the Alexander MCO with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. On
In the United States, the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the TRICARE health plan. One true statement about TRICARE is that
PBM plans operate under several types of contractual arrangements. Under one contractual arrangement, the PBM plan and the employer agree on a target cost per employee per month. If the actual cost per employee per month is greater than the target cost, t
Ronald Canton is a member of the Omega MCO. He receives his nonemergency medical care from Dr. Kristen High, an internist. When Mr. Canton needed to visit a cardiologist about his irregular heartbeat, he first had to obtain a referral from Dr. High to see
Parul Gupta has been covered by a group health plan for eighteen months. For the past four months, she has been undergoing treatment for diabetes. Last week, Ms. Gupta began a new job and immediately enrolled in her new company's group health plan, which
Parable Healthcare Providers, a health plan, recently segmented the market for a new healthcare service. Parable began the process by dividing the healthcare market into two broad categories: non-group and group. Next, Parable further segmented the non-gr
Katrina Lopez is a claims analyst for a health plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Ms. Lopez reviewed a health claim for answers to the following questions:
Question A —
The following programs are part of the Alcove MCO's utilization management (UM) program:
With regard to the UM programs, it is most likely cor
One typical characteristic of an integrated delivery system (IDS) is that an IDS.
Provider integration has two components: operational integration and structural integration. An example of operational integration in health plans is the:
One true statement regarding ethics and laws is that the values of a community are reflected in
The following statement can be correctly made about Medicare Advantage eligibility:
Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves
Phillip Tsai is insured by both a indemnity health insurance plan, which is his primary plan, and a health plan, which is his secondary plan. Both plans have typical coordination of benefits (COB) provisions, but neither has a nonduplication of benefits p
The Acme HMO recruits and contracts directly with a wide range of physicians—both PCPs and specialists—in its geographic area on a non-exclusive basis. There is no separate legal entity that represents and negotiates the contracts for the physicians. The
Natalie Chan is a member of the Ultra Health Plan. Whenever she needs non-emergency medical care, she sees Dr. David Craig, an internist. Ms. Chan cannot self-refer to a specialist, so she saw Dr. Craig when she experienced headaches. Dr. Craig referred h
As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor's practices or services are better than its own, Lyric im
Ashley Martin is covered by a managed healthcare plan that specifies a $300 deductible and includes a 30% coinsurance provision for all healthcare obtained outside the plan’s network of providers. In 1998, Ms. Martin became ill while she was on vacation,
Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:
For this question, select the answer choice containing the terms that correctly complete the blanks labeled A and B in the paragraph below.
NCQA offers Quality Compass, a national database of performance and accreditation information submitted by managed
TESTED 15 Oct 2025
