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One characteristic of the accreditation process for MCOs is that

A.

an accrediting agency typically conducts an on-site review of an MCO's operations, but it does not review an MCO's medical records or assess its member service systems

B.

each accrediting organization has its own standards of accreditation

C.

the accrediting process is mandatory for all MCOs

D.

government agencies conduct all accreditation activities for MCOs

Mr. George Bush is covered by a PBM plan that uses a closed formulary. This indicates that

A.

he can receive coverage for pharmaceuticals only if they are on the PBM plan's preferred list of drugs

B.

he must receive all of his pharmaceuticals from a mail-order pharmacy program

C.

he can receive coverage for pharmaceuticals that are on the PBM plan's preferred list of drugs, as well as for pharmaceuticals that are not on the preferred list

D.

the PBM plan cannot receive a rebate on any pharmaceuticals it obtains from the pharmaceutical facture

Patrick Flaherty's employer has contracted to receive healthcare for its employees from the Abundant Healthcare System. Mr. Flaherty visits his primary care physician (PCP), who sends him to have some blood tests. The PCP then refers Mr. Flaherty to a special

A.

an integrated delivery system (IDS)

B.

a Management Services Organization (MSO)

C.

a Physician Practice Management (PPM) company

D.

a physician-hospital organization (PHO)

The administrative simplification standards described under Title II of HIPAA include privacy standards to control the use and disclosure of health information. In general, these privacy standards prohibit

A.

all health plans, healthcare providers, and healthcare clearinghouses from using any protected health information for purposes of treatment, payment, or healthcare operations without an individual's written consent

B.

patients from requesting that restrictions be placed on the accessibility and use of protected health information

C.

transmission of individually identifiable health information for purposes other than treatment, payment, or healthcare operations without the individual's written authorization

D.

patients from accessing their medical records and requesting the amendment of incorrect or incomplete information

Primary care case managers (PCCMs) provide case management services to eligible Medicaid recipients. With regard to PCCMs it is correct to say that:

A.

PCCMs typically receive a case management fee, rather than reimbursement for medical services on a FFS basis, for the services they provide to Medicaid recipients.

B.

All Medicaid recipients who live in rural areas must be given a choice of at least four PCCMs.

C.

PCCMs receive a case management fee in addition to reimbursement for medical services on a FFS basis.

D.

PCCMs contract directly with the federal government to provide case management services to Medicaid recipients.

Marlee Whitcomb was covered as a dependent under the group health plan provided by her father's employer. That health plan complied with the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986. When Ms. Whitcomb married, she c

A.

can continue her group coverage for a period not to exceed 48 months

B.

can continue her group coverage for a period not to exceed 36 months

C.

cannot continue her group coverage, but has the right to convert the group coverage to an individual health plan

D.

can continue her group coverage indefinitely

The Blaine Healthcare Corporation seeks to manage its quality by first identifying the best practices and best outcomes for a given procedure. Blaine can then determine areas in which it can emulate the best practices in order to equal or surpass the best

A.

provider profiling

B.

benchmarking

C.

peer review

D.

quality assessment

One distinction that can be made between a staff model HMO and a group model HMO is that, in a staff model HMO, participating physicians are Back to Top

A.

Employees of the HMO

B.

Employees of a group practice that has contracted with the HMO

C.

Compensated primarily through capitation

D.

Limited to primary care physicians (PCPs)

John Kerry's employer has contracted to receive healthcare for its employees from the Democratic Healthcare System. Mr. Kerry visits his PCP, who sends him to have some blood tests. The PCP then refers Mr. Kerry to a specialist who hospitalizes him for on

A.

a physician practice organization

B.

a physician-hospital organization

C.

a management services organization

D.

an integrated delivery system

Managed behavioral health organizations (MBHOs) use several strategies to manage the delivery of behavioral healthcare services. The following statements are about these strategies.

Select the answer choice that contains the correct statement.

A.

MBHOs generally provide benefits for mental health services but not for chemical dependency services.

B.

The level of care needed to treat behavioral disorders is the same for all patients and all disorders.

C.

By using outpatient treatment more extensively, MBHOs have decreased the use of costly inpatient therapies.

D.

PCP gatekeeper systems for behavioral healthcare generally result in more accurate diagnoses, more effective treatment, and more efficient use of resources than do centralized referral systems.