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.
a. contractually provide limits and quotas for services
b. encourage them to reduce or limit patient services
c. prevent physicians from receiving payment for services
d. underwrite exotic travel and other bonuses for services
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Q. 2) 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.
a. credentialing statements
b. gag clauses
c. physician incentives
d. profit margins
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Q. 3) 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.
a. preauthorization
b. prospective review
c. retrospective review
d. second surgical opinion
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Q. 4) Which involves the development of patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner?
a. case management
b. risk management
c. quality management
d. utilization management
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Q. 5) Some managed care plans contract out utilization management services to a utilization review organization (URO), which is an entity that __________.
a. conducts a quality management program and completes focused review studies and medical audits
b. establishes a utilization management program and performs external utilization review services
c. performs risk management activities that result in appropriate in-service education for medical staff
d. provides a service to the organization to ensure that physicians have met credentialing requirements
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Q. 6) Which involves arranging appropriate health care services for the patient who is being released from an inpatient hospitalization?
a. concurrent review
b. discharge planning
c. preadmission certification
d. preauthorization
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Q. 7) Which is a review for medical necessity of tests and procedures ordered during an inpatient hospitalization?
a. concurrent review
b. discharge planning
c. preadmission certification
d. preauthorization
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Q. 8) Which is a review that grants prior approval for reimbursement of a health care service?
a. concurrent review
b. discharge planning
c. preadmission certification
d. preauthorization
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Q. 9) Which is a review for medical necessity of inpatient care prior to the patient's admission?
a. concurrent review
b. discharge planning
c. preadmission certification
d. preauthorization
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Q. 10) 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.
a. prospective; retrospective
b. retrospective; prospective
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