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?
a. health information management
b. risk management
c. quality management
d. utilization management
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Q. 2) The National Committee for Quality Assurance (NCQA) reviews managed care plans and develops report cards to __________.
a. allow health care consumers to make informed decisions when selecting a plan
b. control the quality and utilization of health care services to patient populations
c. establish punitive monetary penalties that are paid by poor quality providers
d. guarantee the financial stability of managed care plans and their organizations
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Q. 3) Medicare established the Quality Improvement System for Managed Care (QISMC) to ensure the accountability of managed care plans in terms of objective, measurable __________.
a. laws
b. mandates
c. regulations
d. standards
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Q. 4) Many states have enacted legislation requiring a(n) __________ to review health care provided by managed care organizations.
a. external quality review organization
b. group of community members
c. subcommittee of state legislators
d. task force of out-of-state providers
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Q. 5) A quality assurance program includes activities that __________ the quality of care provided in a health care setting.
a. assess
b. deny
c. provide
d. quantify
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Q. 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.
a. laws
b. procedures
c. regulations
d. standards
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Q. 7) The primary care provider (PCP) is responsible for __________.
a. being a gatekeeper to provide services at the highest possible cost
b. denying all referrals to specialists and inpatient hospital admissions
c. providing nonessential health care services to all patients
d. supervising and coordinating health care services for enrollees
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Q. 8) 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 ___________.
a. distributes to all patients in the practice
b. keeps to reinvest in the medical practice
c. pays back to the managed care organization
d. reimburses to government third-party payers
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Q. 9) 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.
a. enrollees
b. patients
c. payers
d. providers
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Q. 10) Which program resulted from the Balanced Budget Act of 1997 (BBA) and requires that quality assurance activities are performed to improve the functioning of Medicare Advantage (Medicare Part C) organizations?
a. peer review organization (PRO)
b. professional standard review organization (PSRO)
c. quality assessment and performance improvement (QAPI)
d. quality review organization (QIO)
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