United States Health Care System Combining Business Health And Delivery 3rd Ed by Anne Austin – Test Bank

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The U.S. Health Care System, 3e (Austin)

Chapter 3   The Payment Process: Insurance and Third-Party Payers

 

1) What is health insurance?

  1. A) A PPO
  2. B) Shifting the risk of loss
  3. C) An HMO
  4. D) All of the above

Answer:  D

 

2) A third-party payer may be

  1. A) an insurance company
  2. B) a government agency
  3. C) a managed care organization
  4. D) all of the above

Answer:  D

 

3) The ________ calculates risk and helps set premiums.

  1. A) actuary
  2. B) government
  3. C) benefits manager
  4. D) employer

Answer:  A

 

4) John’s recent physician’s office visit was not paid by the insurance company. It was his first claim of the year. The claim totaled $200. The reason the claim was denied was likely related to John’s

  1. A) copayment
  2. B) subscriber
  3. C) deductible
  4. D) premium

Answer:  C

 

5) A deductible is the

  1. A) portion of services paid by the patient
  2. B) amount paid by the patient before the third-party payer begins to pay
  3. C) fee paid by employers and employees to the insurance company
  4. D) negotiated payment for services between the payer and the provider

Answer:  B

 

6) The copayment is the

  1. A) fee paid by employers and employees to the insurance company
  2. B) negotiated payment for services between the payer and the provider
  3. C) portion of services paid by the patient
  4. D) amount paid by the patient before the third-party payer begins to pay

Answer:  C

7) Premiums are the

  1. A) portion of services paid by the patient
  2. B) amount paid by the patient before the third-party payer begins to pay
  3. C) negotiated payment for services between the payer and the provider
  4. D) fee paid by employers and employees to the insurance company

Answer:  D

 

8) A policy is

  1. A) a binding contract that describes all the terms of insurance
  2. B) the time in which employees can utilize benefits
  3. C) a time when employees can change providers
  4. D) a binding contract between the payer and the employee

Answer:  A

 

9) An enrollment period is the

  1. A) time when a policy lapses
  2. B) time when companies determine which policy pays
  3. C) time when employees can sign up for benefits
  4. D) all of the above
  5. E) none of the above

Answer:  C

 

10) Determining which third-party pays for services is known as

  1. A) explanation of benefits
  2. B) COBRA
  3. C) coordination of benefits
  4. D) ERISA

Answer:  C

 

11) A person who signs up for insurance coverage through an employer is a (an)

  1. A) actuary
  2. B) enrollee
  3. C) subscriber
  4. D) policy holder

Answer:  B

 

12) All of the following are true about the Healthcare Common Procedure Coding System (HCPCS), EXCEPT

  1. A) it consists of two levels
  2. B) the current procedural terminology (CPT) is for procedures and services performed by providers
  3. C) it involves indemnification
  4. D) the national codes (HCPCS level II codes) are for procedures, services, and supplies not found in CPT

Answer:  C

 

 

13) Which of the following describes Blue Cross/Blue Shield?

  1. A) A health insurance company
  2. B) A type of prepaid service
  3. C) Mostly are nonprofit organizations
  4. D) All of the above

Answer:  D

14) A method of reimbursing providers based on what other providers are paid for a particular service is known as the

  1. A) usual charge and reasonable cost plan.
  2. B) usual, customary, and reasonable price
  3. C) universal charge and reimbursement plan
  4. D) ordinary and customary cost program

Answer:  B

 

15) A key function in a managed care model is

  1. A) gatekeeping
  2. B) prepayment
  3. C) processing fees
  4. D) indemnifying losses

Answer:  A

 

16) A payment method under which each patient receives a set dollar amount of services is known as the

  1. A) premium
  2. B) capitation
  3. C) copayment
  4. D) deductible

Answer:  B

 

17) An HMO contracts with more than one group practice for service in which arrangement?

  1. A) Staff model HMO
  2. B) Network HMO
  3. C) IPA
  4. D) PPO

Answer:  B

 

18) Prepaid health plans

  1. A) are attractive to employers because they know in advance what the cost of providing health care will be
  2. B) all involve an IPO
  3. C) are attractive to the service provider because the number of patients is fixed and a certain revenue level is guaranteed
  4. D) relate to both A and C

Answer:  B

 

 

19) A ________ is a system where payment is made in advance of services being provided.

  1. A) prepaid health plan
  2. B) preauthorization
  3. C) coordination of benefits
  4. D) copayment

Answer:  A

 

20) This organization negotiates and manages provider’s contracts.

  1. A) Staff model HMO
  2. B) PPO
  3. C) Network HMO
  4. D) IPA

Answer:  B

21) Which regulates portability, access, and mandated benefits at the federal level?

  1. A) COBRA
  2. B) HIPAA
  3. C) EPO
  4. D) ERICA

Answer:  B

 

22) With EPOs, all of the following are true, EXCEPT

  1. A) patients must select their care providers from those in the network
  2. B) patients may choose their physician or hospital
  3. C) if the patient chooses to go outside the network, the services are not covered
  4. D) they are regulated by state insurance law

Answer:  B

 

23) A PPO

  1. A) is a delivery network
  2. B) does not receive premiums or assume financial risk
  3. C) decreases cost of service if a preferred provider is used
  4. D) represents all of the above

Answer:  D

 

24) All are true regarding regulation of third-party payers, EXCEPT

  1. A) insurers who sell any type of insurance are regulated
  2. B) only health insurance companies must be licensed
  3. C) the insurance commission is charged with regulatory authority
  4. D) regulation attempts to ensure policy holders receive the coverage they purchase

Answer:  B

 

 

25) HIPAA regulates all of the following, EXCEPT

  1. A) portability
  2. B) coverage on a family plan until 26 years old
  3. C) access
  4. D) mandated benefits

Answer:  B

 

26) Employers must provide health insurance.

Answer:  FALSE

 

27) Employers pay the entire insurance premium for their employees in most instances.

Answer:  FALSE

 

28) Approximately 14 million people are without health insurance.

Answer:  FALSE

 

29) Physicians are always independent contractors in third-party payer arrangements.

Answer:  FALSE

 

30) Like hospitals, insurance companies must be licensed.

Answer:  TRUE

 

31) According to the text, ________% of Americans under age 65 are uninsured.

Answer:  about 16

32) ________ insurance does not restrict a patient’s choice of providers.

Answer:  Indemnity

 

33) In a ________, the employer acts as the insurance company and pays for its employees’ health care costs out of its own pocket.

Answer:  self-insured plan

 

34) ________ administer health care benefits and process claims for their clients.

Answer:  Third-party administrators

 

35) A(n)________ is a type of prepaid health care plan.

Answer:  HMO

 

36) Define the term third-party payer and describe the role of the insurance company as the third party in the patient-provider relationship.

Answer:  Responses will vary, but should include that the patient contracts with the insurance company to pay the provider for services rendered to the patient.

 

 

37) Explain the gatekeeping concept, and include an example of how it benefits the patient, payer, and provider.

Answer:  Responses will vary, but should include:

The patient can only access certain services from the primary care provider and can only obtain specialist and rehabilitative services if referred by the primary provider. This provides cost savings because only patients who are judged to need them have access to more expensive care.

 

 

The U.S. Health Care System, 3e (Austin)

Chapter 9   Mental Health Services: A Combination of Systems

 

1) The discovery of a biochemical basis for some of the major categories of mental illness led to all of the following changes, EXCEPT

  1. A) changes from residential care to outpatient talk therapy
  2. B) changes from physical or somatic treatments to treatments relying on drug therapy
  3. C) changes from treatments relying on drug therapy to somatic and physical treatments
  4. D) changes from the institutional model of care to a general delivery and business model

Answer:  C

 

2) A diagnosis of mental illness is determined

  1. A) solely through measurable parameters
  2. B) solely through functional ability
  3. C) through a combination of objective and subjective data
  4. D) through response to prior treatment

Answer:  C

 

3) All of the following describe mental illnesses, EXCEPT

  1. A) alterations in thinking
  2. B) alterations in behavior
  3. C) alterations in liver function
  4. D) alterations in mood

Answer:  C

 

4) Mental illness, including drug abuse, affects ________ of the U.S. population.

  1. A) less than 10%
  2. B) greater than 20%
  3. C) greater than 30%
  4. D) less than 20%

Answer:  A

 

5) All of the following are true regarding mental illness, EXCEPT

  1. A) around 45% of adults suffer from substance abuse
  2. B) around 80% do not receive treatment
  3. C) most are a chronic lifetime disease
  4. D) it strikes one in every five adults

Answer:  A

 

6) Among the public payers of mental health care, ________ pays the most.

  1. A) Medicaid
  2. B) Medicare
  3. C) state and local agencies
  4. D) Department of Veterans Affairs

Answer:  A

 

7) Which is TRUE regarding mental health services?

  1. A) Less than one-half of adults with a mental health disorder receive services.
  2. B) Direct state funding of mental health care has increased.
  3. C) Medicaid funding of mental health care has grown.
  4. D) Generally, the same providers are used for treatment of mental illness and substance abuse.

Answer:  C

 

8) Because of its substantial role in financing mental health services, ________ has significant influence in designing mental health service delivery.

  1. A) Medicaid
  2. B) Medicare
  3. C) Blue Cross/Blue Shield
  4. D) private insurance

Answer:  A

 

9) Which of the following is NOT a category of human resource components in mental health care?

  1. A) Specialty mental health sector
  2. B) Home health sector
  3. C) General medical/primary care sector
  4. D) Human services sector

Answer:  B

 

10) Which of the following is NOT a type of treatment for mental illness?

  1. A) Psychotherapy
  2. B) Ablation
  3. C) Drug therapy
  4. D) Electroshock therapy

Answer:  B

 

11) Which is part of the specialty mental health sector?

  1. A) Alcoholics Anonymous
  2. B) Prison-based services
  3. C) Psychiatrist
  4. D) Primary care physician

Answer:  C

 

12) Which of the following is NOT true about the human services sector?

  1. A) They assesses, diagnose, and treat childhood mental illness and cognitive disorders.
  2. B) Self-help groups play a major role for this group.
  3. C) Social services and school-based counseling belong to this sector.
  4. D) Religious counselors belong to this sector.

Answer:  B

 

 

13) Which era focused on prevention and scientific orientation?

  1. A) Moral era
  2. B) Mental hygiene era
  3. C) Community mental health era
  4. D) Current community support era

Answer:  B

14) Human restorative treatment was the focus of which mental illness treatment period?

  1. A) Mental hygiene era
  2. B) Community mental health era
  3. C) Current community support era
  4. D) Moral treatment era

Answer:  D

 

15) The state care acts

  1. A) centralize the care into one or two state mental hospitals that cared for thousands of residents at a time
  2. B) called for an expansion of neuropathology in mental hospitals
  3. C) called for bringing mental health services to the public in their communities
  4. D) investigated the results of consumer-operated program outcomes for people with mental illness

Answer:  A

 

16) All the following are major causes of disability for women, EXCEPT

  1. A) depression
  2. B) bipolar disease
  3. C) schizophrenia
  4. D) obsessive compulsive disorder

Answer:  D

 

17) This medical disorder involves the body, mood, and thoughts.

  1. A) Alzheimer’s
  2. B) Schizophrenia
  3. C) Depression
  4. D) Anxiety disorder

Answer:  C

 

18) Deinstitutionalization of people committed to psychiatric hospitals and changes in psychiatric treatment led to all of the following, EXCEPT

  1. A) self-help programs
  2. B) drop-in centers
  3. C) case-management services
  4. D) fewer treatment options

Answer:  D

 

 

19) All of the following are examples of mental disorders, EXCEPT

  1. A) Alzheimer’s
  2. B) schizophrenia
  3. C) anorexia
  4. D) Parkinson’s

Answer:  D

 

20) All the following are true regarding suicide, EXCEPT

  1. A) men attempt suicide three times more often than women
  2. B) there are approximately 25 suicide attempts for every death
  3. C) ninety percent suffer from substance abuse or a diagnosable depressive disorder
  4. D) in 2006, the highest rates occurred in white men over the age of 85

Answer:  A

21) Hallucinations are characteristic of

  1. A) schizophrenia
  2. B) anxiety disorders
  3. C) Alzheimer’s
  4. D) depression

Answer:  A

 

22) Which is TRUE regarding schizophrenia?

  1. A) It appears in men in their late teens or early twenties.
  2. B) Over fifty thousand new cases are diagnosed each year.
  3. C) If one twin exhibits symptoms, the other twin will not become symptomatic.
  4. D) Affects four times more women than men.

Answer:  A

 

23) Feelings of dread, fear, and apprehension are indicative of

  1. A) anxiety disorders
  2. B) depression
  3. C) schizophrenia
  4. D) Alzheimer’s

Answer:  A

 

24) Hyperventilation and tachycardia often accompany

  1. A) panic disorder
  2. B) generalized anxiety disorder
  3. C) posttraumatic stress disorder
  4. D) obsessive-compulsive disorder

Answer:  A

 

 

25) All the following are true regarding posttraumatic stress disorder, EXCEPT it

  1. A) involves frequent occurrence of flashbacks
  2. B) generally manifests within 3 months of a terrifying event
  3. C) affects ten times more men than women
  4. D) is accompanied by depression, substance abuse, and anxiety

Answer:  C

 

26) Which disorder is predominantly associated with children?

  1. A) Attention-deficit/hyperactivity disorder
  2. B) Posttraumatic stress disorder
  3. C) Schizophrenia
  4. D) Generalized anxiety disorder

Answer:  A

 

27) Which of the following is NOT a possible risk factor for mental illness?

  1. A) Family history
  2. B) Lack of social support
  3. C) Inability to read
  4. D) Strong support system

Answer:  D

28) Which of the following is NOT an ethical issue in mental health?

  1. A) Confidentiality
  2. B) Access
  3. C) Economics
  4. D) Ageism

Answer:  D

 

29) More U.S. adults suffer from substance abuse than from mental illness.

Answer:  FALSE

 

30) The parity of payment to consumers is a major goal of mental health legislation.

Answer:  TRUE

 

31) Historically, mentally ill people were considered possessed by evil spirits.

Answer:  TRUE

 

32) The movie One Flew over the Cuckoo’s Nest was a dramatic portrayal of the state’s response to the state care acts.

Answer:  TRUE

 

33) Racism is a barrier to a person accessing mental health services.

Answer:  TRUE

 

34) Mental illness, like physical illness, is defined the same way by every culture.

Answer:  FALSE

 

35) ________ calls for equity in mental health and general health coverage.

Answer:  Parity

 

36) The major sector that assesses, diagnoses, and treats childhood mental illness and cognitive disorders is the ________.

Answer:  human services sector

 

37) ________ is a major concern of patients with mental illness because of the stigma and possible occupational repercussions if the condition were known.

Answer:  Confidentiality

 

38) List three of the identified mental health treatment types identified in the text.

Answer:  Answers will vary, but should include three of the following: self-help, psychotherapy, talk therapy, behavioral therapy, drug therapy, or device therapy.

 

39) List three of the identified mental health care settings.

Answer:  Answers will vary, but should include three of the following: home care, community-based residential care, day care, sheltered work setting, outpatient facilities, private psychiatric and recovery institutions, public emergency facilities, or public long-term-care facilities

 

40) Discuss issues related to children and mental health.

Answer:  Responses will vary, but should address the following: Diagnosis, care delivery systems, care givers, and therapies.

41) Explain some of the factors that result in the underutilization of mental health services.

Answer:  Responses will vary, but should include systemic, economic, stigma, and cultural factors.

 

United States Health Care System Test Bank,

 

 

 

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