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Medical Practice Strategies:  Systems Based Practice - Business Laws Ethics

Janet Lerman, J.D.

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CME Test - Class 2

This is a multiple-choice test.  Input the best answer corresponding to the attached readings in the form below.  Upon Completion of the CME Test please complete the Evaluation of this class and submit (See Evaluation link above). 

CME Test Class 2  --  form for test completion

Are you registered for this class?

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If you are registered, please complete the following CME Test for Class 2: 

1.   List three forms of review that utilization review departments of Managed Care Organizations (MCO) might use.  (Reference Class 2, "Standards of Care" - "Common Standards for Case Management")

Question 1 choices:

A B C D E    

A.    Prospective review, concurrent review, and retrospective review.

B.    Gatekeeper review, MCO review, and Joint Commission of Health care Organizations (JCAHO) review.

C.    Legal review, risk management review, grievance committee review.

D.    Peer review, administrative review, and risk management review.

E.    None of the above.

2.    Dr. Jones has entered into a capitated agreement with a HMO.  What are some issues that Dr. Jones should consider in regards to costs of rendering medical care to the capitated patients?  (Reference Class 2, "Business Side" - "Identify Business Aspects of Practice and Cost-Effective Care") 

Question 2 choices:

A B C D E    

A.    Dr. Jones should consider what his costs are of rendering medical care to the capitated patients because if Dr. Jone's costs of rendering care exceeds the amount of the capitation rate, then Dr. Jones is losing money and Dr. Jones might want to re-think what his alternatives are in this particular situation. 

B.    Dr. Jones should consider how he is going to be able to manage costs.

C.    Dr. Jones should be able to track incurred but not reported (IBNR) liabilities incurred through referral of HMO patients to specialists in which Dr. Jones is responsible for payment to such specialists.

D.    All of the above.

E.    Dr. Jones does not need to be concerned about costs of rendering medical care under these circumstances.

3.    What does fee-for-service mean?  (Reference Class 2, "Comparable Costs" - "Common and Comparable Costs Per Type of Services Provided")

Question 3 choices:

A B C D E   

A.    Fee-For-Service basically means costs plus a profit margin that providers bill for their services after such services were rendered and are usually based on usual, customary, and reasonable charges for such type of services rendered within a certain vicinity and may include factors such as level of training required to perform such services.

B.    Fee-For-Service is the same thing as capitation.

C.    Fee-For-Service is the same thing as discounted fee-for-service.

D.    Fee-For-Service is basically a discounted fee schedule determined in advance of any medical care services being rendered.

E.    None of the above.

4.    What does discounted-fee-for-service mean?  (Reference Class 2, "Comparable Costs" - "Common and Comparable Costs Per Type of Service Provided")

Question 4 choices:

A B C D E   

A.    Discounted-Fee-For-Service means the same thing as capitation.

B.    Discounted-Fee-For-Service means a discounted rate in which providers are reimbursed for rendering services such as taking the usual and customary and reasonable charges within a certain vicinity and providers agreeing to accept 90% of charges instead of the usual 100%.

C.    Discounted-Fee-For-Service means the same thing as Fee-For-Service.

D.    Discounted-Fee-For-Service means a percentage of the copayment or out of pocket expense paid to the provider by the patient.

E.    None of the above.

5.    Dr. Jones is just starting to set up his own medical practice.  He is thinking about his billing system and he has been appointed on staff at a nearby hospital.  He is wondering if the hospital uses a particular billing system.  What are two uniform billing coding systems commonly used in the United States that Dr. Jones might be using?  (Reference Class 2, "Common Language" - "Common Language of Services Provided: Billing Codes")

Question 5 choices:

A B C D E   

A.    Two coding systems commonly used in the United States:  Fee-For-Service and Discounted-Fee-For-Service. 

B.    Two coding systems commonly used in the United States: Capitation and utilization management.

C.    Two coding systems commonly used in the United States: International Classification of Disease, 9th Edition, United States version ("ICD-9-CM") primarily for inpatient care and Current Procedures and Terminology -4 (CPT-4) primarily for office-based and procedures oriented care.

D.    There is no such thing as a uniform billing coding systems commonly used in the United States.

E.    None of the above.

6.    Dr. Fred, 62 years old, has been practicing medicine for many years.  He has heard some buzz about "TQM" and "CQI"  He wonders what those acronyms stand for and what do they do.  What does "TQM" and "CQI" stand for and do?  (Reference Class 2, "Relevant Terms" - "Quality Assurance Programs") 

Question 6 choices:

A B C D E    

A.    "TQM" stands for Total Quality Management.   

B.    Total Quality Management ("TQM") involves establishing quality standards and educating providers and patients about them.

C.    ("CQI") stands for Continuous Quality Improvement.

D.    Continuous Quality Improvement ("CQI") not only utilizes standards but also has defined goals of ongoing increases in the level of quality of care given and outcomes. 

E.    All of the above.

7.    Dr. Sam just started practicing medicine and opened an office in the small town he grew up in.  He has heard something about a National Practitioner Data Bank ("NPDB") and wonders what that has to do with him, if at all.  What relevance is the National Practitioner Data Bank ("NPDB") to Dr. Sam?  (Reference Class 2, " Relevant Terms" - "Quality Assurance Programs") 

Question 7 choices:

A B C D E   

A.    Dr. Sam does not need to be aware of the National Practitioner Data Bank ("NPDB") because it does not apply to physicians, therefore it is not relevant.

B.    Lack of quality care must, in some cases, result in punitive action, including reporting to the National Practitioner Data Bank ("NPDB").

C.    The National Practitioner Data Bank ("NPDB") is a financial institution only for physicians

D.    All of the above.

E.    None of the above.

8.    Diagnosis Related Groups ("DRGs") was implemented by the U.S. federal government in the early 1980s as a payment tool for hospitalized Medicare patients.  What are some factors that were considered in the development of this Medicare inpatient prospective payment system ("PPS") of DRGs?  (Reference Class 2, "Common Language of Services Provided")

Question 8 choices:

A B C D E    

A.    Class definitions based on information routinely collected on hospital abstracts.

B.    Manageable number of classes.

C.    Similar patterns of resource intensity within a given class.

D.    Similar types of patients in a given class from a clinical perspective.

E.    All of the above.

9.    What are some responsibilities that HMO Medical Directors may have?  (Reference Class 2, " HMOs" - Health Maintenance Organizations")

Question 9 choices:

A B C D E    

A.     Responsibilities of HMO Medical Directors typically include analyzing and implementing quality standards.

B.    HMO Medical Directors may become involved in more difficult or complicated negotiations with providers.

C.    Responsibilities of HMO Medical Directors typically include utilization management such as determining if specific treatments are appropriate, necessary, or covered.

D.    All of the above.

E.    None of the above.

10.    What is the purpose of "risk-sharing" or "withholding" pools? (Reference Class 2, "Risk Management")

Question 10 choices:

A B C D E    

A.    The purpose of "risk-sharing" or "withholding" pools is to set aside money to help patients pay for copayments.

B.    The purpose of "risk-sharing" or "withholding" pools is to set aside money to help patients pay for deductibles.

C.    The purpose of "risk-sharing" or "withholding" pools is to encourage appropriate use of specialist and hospital related fees, such as to reduce unnecessary or duplicitous care.

D.    All of the above.

E.    None of the above.

 

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