HSM 420 Midterm Exam

HSM 420 Midterm Exam

1. (TCO
1) Why were the first proto-HMOs formed in America? What were the original
driving factors in the HMO movement?

2.(TCO 1) What is meant by indemnity coverage, and
how does it change in managed indemnity?

3. (TCO
2) What is the role of the executive director in a managed care organization?
Could you see yourself practicing in this position at some point in your career?
Why or why not?

4. (TCO
2) What is the role of the Peer Review Committee in a managed care
organization? And why is this function so crucial?

5. (TCO
3) Describe the calculation of capitated payments. How are these rates
determined in managed care organizations?

6. (TCO 3) Describe the use of evidence-based
clinical criteria in managed care. Why is this process so important in managed
care today?

7. (TCO 4) What is meant by pattern review
under managed care? Why do payers conduct pattern review, and what kinds of
things might they identify during such reviews?

8.(TCO 4)
Discuss some key general aspects of physician practice behavior? Include
implicit messages from training, and also environmental factors, in your
answer.

9. (TCO 7) What is the purpose of
hold-harmless and balance-billing clauses in managed care contracts?

10.(TCO 7) What is typically covered
under “term, suspension, and termination” of a managed care contract?

Explanation & Answer

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