Chapter 2 Review Quiz Student Version
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University of Kansas *
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Course
BES12
Subject
Health Science
Date
Dec 6, 2023
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docx
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2
Uploaded by SargentMorningGerbil25
20 Points
1.
Define the term risk pool.
In the textbook, risk is defined as the likelihood of an individual to incur a healthcare expense or
the
probability of incurring a loss. 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.
2.
What is the relationship between covered conditions and covered services in health insurance
plans?
Covered services are healthcare services that the insurance company will pay as outlined in the
healthcare plan. Covered conditions are health conditions, illnesses, injuries, diseases or symptoms
that the health insurance company will reimburse for treatment that attempts to maintain, control,
or cure said conditions. Both these provisions describe to the policyholder what they can expect
from their healthcare insurance plan.
3.
List three synonyms for policyholder.
Insured, beneficiary, member are three synonyms for policyholder.
4.
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.
5.
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. Its written out in plain simple
language so that a consumer will understand the information about coverage.
6.
Describe at least three ways in which MCOs work toward their goals of quality patient care?
Selection of providers selected based on quality, scope of services, cost and location. Managed care
plans stress the use of this criteria.
Care management tools like disease management which focuses on preventing exacerbations or
flare-ups of chronic diseases. As well as promoting healthier lifestyles for patients.
Quality assessment and improvement like cost-effective care, controls to provide this goal are to
have prospective reimbursement, and financial incentives.
7.
W
here 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)
8.
Name the three steps in utilization review.
The three steps in utilization review:
Initial clinical review – review against established criteria
A peer clinical review – clinician qualified to render clinical opinion performs clinical review
Appeals consideration/decision – clinician not involved in initial decision but qualified to render
clinical opinion performs clinical review.
pg. 1
CHAPTER 2 QUIZ ANSWER KEY
9.
Define Adverse selection.
Adverse selection is defined as the occurrence in health insurance when there is an imbalance of
high-risk, sick policyholders to healthy policyholders.
10.
Describe three mechanisms used by MCOs to ensure cost-effective care.
Medical necessity and utilization contain and monitor use of healthcare services by evaluating the
need for and intensity of the service prior to it being provided
Prior approval is the formal administrative process of obtaining prior approval for healthcare
services.
Utilization review evaluates both effectiveness and efficiency.
pg. 2
CHAPTER 2 QUIZ ANSWER KEY
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