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HSM 420 Midterm Exam

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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?

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) Wh
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