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HSM 546 Health Ins and Managed
Care Week 8 Final Exam
Complete A+ Answer

HSM 546 Health Ins and Managed Care Week 8 Final Exam Complete A+ Answer
HSM 546 Health Ins and Managed Care Week 8 Final Exam Complete A+ Answer
1. (TCO B) The original impetus of HMO development came from which of the following?
(Points : 5)
Providers seeking patient revenues
Consumers seeking access to healthcare
Employers
All of the above
None of the above
Question 2. 2. (TCO A) Key common characteristics of PPOs include _____.
(Points : 5)
selected provider panels
negotiated payment rates
consumer choice
utilization management
All of the above
A, B, and D only
Question 3. 3. (TCO B) Managed care is best described as _____.
(Points : 5)

an insurance company that provides health services

a broad and constantly changing array of health plans that attempt to manage both cost
and quality of care
an inexpensive form of payment for health services
Question 4. 4. (TCO D) Carve-outs within a capitation contract can be defined as _____.
(Points : 5)
stop-loss reinsurance provisions
risk/bonus arrangements within capitation
services billable outside of a capitation payment
per diem rates
Question 5. 5. (TCO B) Which of the following forms of hospital reimbursement contain
no elements of risk sharing by the hospital? (Points : 5)
Capitation
DRGs
Per diem
Sliding scale FFS
Both C and D
Question 6. 6. (TCO C) Electronic prescribing offers which of the following potential
outcomes? (Points : 5)
Increased physician and pharmacy efficiency, but no cost savings
Reduction in prescribing and dispense errors, but at a high member cost
Greater efficiency in the prescribing and dispensing process, as well as reduced
medication-related errors
Lower costs and higher rate of medication errors
Question 7. 7. (TCO C) Which organization does not accredit managed behavioral
healthcare companies? (Points : 5)
NCQA
JCAHO
URAC
Council on Accreditation
American College of Mental Health Administration
Question 8. 8. (TCO C) Which of the following are components of a strong MCO
prevention program? (Points : 5)
Member benefits
Services for members, such as health risk assessments
Contracts with providers
Public policies
A and C only
A, B, C, and D
Question 9. 9. (TCO D) This federal law has established specific, enforceable regulations
to help ensure the privacy and confidentiality of individual health information. (Points : 5)
OCR

HEDIS
HIPAA
EMTALA
Question 10. 10. (TCO D) The Health Plan Employer Data and Information Set (HEDIS)
is a measurement tool used by about what percentage of all health plans. (Points : 5)
90%
67%
3%
48%
Question 11. 11. (TCO D) Which of the following does HIPAA regulate? (Points : 5)
Electronic communications between payors and providers
Portability and access standards
Guaranteed renewability of group coverage
All of the above
Question 12. 12. (TCO D) Which of the following payment issues should be covered in the
managed care contract? (Points : 5)
The payment responsibilities for copayments
The payment responsibilities for uncovered services
The reconciliation to account for overpayments or underpayments
All of the above
1. (TCO G) Who are the customers of managed care
2. 2. (TCO G) Discuss ERISA preemption of state insurance laws and mandates. Discuss
the implications of this preemption. (Points : 10)
3. Discuss when an employer would or would not choose to self-fund a health benefits plan
for employees. (Points : 10)
4 How has the concept of value and healthcare for employers as well as employees evolved
over the last few years? Use an example in discussing each perspective. (Points : 10)
5. (TCO E) What is the difference between accreditation and certification? (Points : 10)
6. How are premiums billed and received? (Points : 10)
1. (TCO G) The Administrative Simplification component of HIPAA addresses four issues
of widespread importance to health plans. What is included under the administrative
simplification portion of HIPAA. Why is it important to the healthcare industry? (Points :
30)
2. What is Medicare Part D? What impact has the Medicare Part D drug benefit had on
the healthcare market? (Points : 30)

3. TCO E) Discuss the relationship between employee engagement and per employee
health costs. (Points : 30)
4. TCO C) What is a hospitalist? What is their approach in inpatient care, and when is
such an approach appropriate and when it is not?
5. (TCO C) Preventable diseases In the United States have both a human cost and an
economic impact on society. Discuss the impact that the top five chronic diseases (heart
disease, cancer, stroke, chronic obstructive pulmonary disease, and diabetes) have had on
the overall health status in the United States. (Points : 30)
6.
(TCO G) Compare and contrast the impact (positive and negative) that older adults will
have on health insurance, service access, cost, technology, and providers. (Points : 30)
Additional Questions:
Carla Thomas, a nonsmoker, often encouraged her co-workers to quit smoking. Her new
manager, Paul, a smoker, was annoyed by what he considered her constant nagging. He
moved her desk from a separate room with a window to a cubicle surrounded by smokers,
who smoked all day. Paul refused Carlas request to create a no-smoking area in the office
and he refused her request to be moved back to the separate room. After four weeks of
breathing secondhand smoke, Carla quit. What, if any, recourse does Carla have against
her former employer? Explain the possible legal theories for recovery, if any
2) Mary Smith was an employee of Thomas Contracts, a pipeline construction company.
Mary was supervised by H.D. Thomas, son of the owner of the business. She became
involved in an affair with Thomas, who was married. Thomas ended the affair and
subsequently fired Mary based on her performance since the affair began. Mary filed a
suit against Thomas Contracts, alleging that her discharge was due to gender
discrimination, sex discrimination, and in violation of Title VII. Analyze and determine
what important facts you would need to know in order to ascertain Marys likelihood of
success here.
3) An ambulance service transports disabled individuals on a non-emergency basis. Jane
was hired as a night dispatcher. She worked at home, and was required to be on duty to
take calls for service from 5:00 p.m. to 8:00 a.m., Monday through Thursday, and from
9:00 p.m. Friday to 7:00 a.m. on Monday. She was paid $550 per month. She was not given
any special training, she was simply instructed how to fill in record sheets, and how to call
the ambulance crew to notify them of the service request. Jane was free to engage in
personal business as long as it did not interfere with the calls, and was able to leave her
home as long as she made sure that someone was available to answer the phone.
The ambulance company claimed that Jane was an independent contractor and was
exempt from the FLSAs overtime and wage requirements. Jane filed suit to collect
overtime and minimum wage back pay under the FLSA. Determine whether she will
succeed. If you determine that she will succeed, explain the remedies available. Support
your position with any applicable laws.

4) Generally, an employer must have a sound, work-related reason to require a current

employee to submit to testing. However, even that might not be enough: If the test is too
intrusive or delves too deeply into personal issues, it might unlawfully invade the
employees right to privacy. If it makes you very uncomfortable or seems unrelated to your
employers business interests, then you might be within your rights to cry foul. A federal
law, the Employee Polygraph Protection Act (29 U.S.C. 2001), .
5.As per the case, the store manager, Jeff, is asking Frank to take the polygraph test.
Frank communicates to Jeff that he has not stolen anything and asserts his rights of privay
to not take the test. In this case, the Polygraph test is not too intrusive and doesnt delve
into Franks persoanl issues. Jeff and the company have a sound work-related reason to
require Frank to submit to testing. So, this cant be stated to be interfering with Frankss
right to privacy. It is in the business interest of company that such acts are not performed
by any employee of the company. Even if Frank has not committed the said act, on the
ground of business interest, Jeff has the right to ask for the Polygraph test to Frank. And
Frank, in this case should have complied with this Jeffs request. A federal law, the
Employee Polygraph Protection Act (29 U.S.C. 2001), prohibits most private employers
from requiring their workers to submit to lie detector tests, with one exception and that is if
the employer reasonably suspects of theft or embezzlement to take a polygraph test, if
certain requirements are met. Aside from this limited exception, however, an employer may
not require a current employee to take a lie detector test, use the results of any such test, or
discipline or fire any employee who refuses to take one.
.
6. 39 year old jim, who works for a new 5 year company that employs 30 individuals, feels
that he is being discriminated..

HSM 546 Health Ins and Managed

Care Week 8 Final Exam
Complete A+ Answer