#1
What does HMO stand for in healthcare?
Health Maintenance Organization
ExplanationHMOs use capitation to reimburse providers.
#2
Which of the following is a characteristic of a PPO?
Offers more flexibility in choosing healthcare providers
ExplanationPPOs offer flexible healthcare provider options at reduced costs.
#3
What does EOB stand for in healthcare?
Explanation of Benefits
ExplanationEOB documents explain healthcare benefits and payments.
#4
In managed care, what does the term 'gatekeeper' refer to?
The primary care physician responsible for coordinating a patient's care
ExplanationGatekeepers coordinate care as primary care physicians.
#5
What does COBRA stand for in healthcare?
Consolidated Omnibus Budget Reconciliation Act
ExplanationCOBRA allows employees to continue health coverage after job loss.
#6
What does DRG stand for in the context of healthcare reimbursement?
Diagnostic Related Group
ExplanationDRGs categorize hospital cases for reimbursement purposes.
#7
Which entity regulates Medicare and Medicaid programs in the United States?
Department of Health and Human Services
ExplanationDHHS oversees Medicare and Medicaid programs.
#8
What is the purpose of a formulary in managed healthcare?
To list approved medications for coverage and reimbursement
ExplanationFormularies list approved medications for coverage.
#9
Which of the following is a characteristic of a Health Savings Account (HSA)?
Funds can be invested and grow tax-free
ExplanationHSAs allow tax-free investment and growth of funds.
#10
What is a utilization review in managed healthcare?
An assessment of a patient's medical necessity for certain treatments or services
ExplanationUtilization review assesses medical necessity.
#11
What is adverse selection in the context of insurance?
The tendency for healthier individuals to opt out of insurance coverage
ExplanationAdverse selection occurs when healthier individuals avoid insurance.
#12
Which of the following statements best describes capitation in managed care?
Providers receive a fixed payment per patient enrolled, regardless of services provided
ExplanationCapitation involves fixed payments per enrolled patient.
#13
What is the purpose of a prior authorization requirement in managed care?
To reduce unnecessary healthcare spending
ExplanationPrior authorization lowers unnecessary healthcare costs.
#14
What is a health insurance deductible?
The fixed amount paid by the insured for covered services before insurance coverage kicks in
ExplanationDeductibles are amounts paid before insurance coverage.
#15
What is the main goal of utilization management in managed care?
To ensure appropriate use of healthcare resources and services
ExplanationUtilization management ensures proper resource use.