Chapter 2 Review Quiz
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Health Science
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Feb 20, 2024
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Chapter 2 Review Quiz
Define the term risk pool.
Risk pool is defined as a group of individuals whose medical cost are combined to calculate premiums. It allows the higher costs of the less healthy to be offset by the relatively lower costs of the healthy
What is the relationship between covered conditions and covered services in health insurance plans?
Covered conditions are patient diseases or injuries for which the healthcare plan will pay. The services related to treating covered conditions are covered services.
List three synonyms for policy holders.
Member, insured, certificate holder, subscriber and beneficiary are synonyms for policyholder.
Define deductible.
Deductible is defined as the annual amount of money that the policyholder must pay before the health insurance plan will assume its share of liability for the remaining charges or covered expenses.
What is the purpose of the Summary of Benefits and Coverage (SBC)?
Summary of benefits and coverage is a summary document that concisely details information about a health insurance company’s benefits and coverage of health services. It’s written out in plain simple language so that a consumer will understand the information about coverage.
Describe at least three ways in which MCOs work toward their goals of quality patient care.
MCOs focus on providing quality care by selecting providers carefully, emphasizing the health of their populations, using care management tools, and maintaining accreditation and participation in quality improvement programs.
From where do evidence-based clinical guidelines originate?
They have been systematically developed from scientific evidence and clinical expertise. Sources of these guidelines are the agency for Healthcare Research and Quality (AHRQ).
Name the three steps in utilization review.
The three steps are initial clinical review, peer clinical review, and appeals consideration.
Why is prescription management an important cost control?
Prescription management is an important cost control because it increases the use of a formulary, a list of prescription drugs that health insurance will cover, to an inclusive approach to medications and medication administration.
Describe three mechanisms used by MCOs to ensure cost-effective care.
The three mechanisms used by MCOs to ensure cost-effective care are service management tools, prospective reimbursement, and financial incentives.
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