DLM (ASCP) Exam Preparation
Study online at https://quizlet.com/_j950ls
1. What is the primary goal of managed care To contain costs by controlling the type,
health systems? level, and cost of services provided.
2. What is a capitation system in the context of A payment system that limits what a
managed care? health provider is paid for patient ser-
vices under a managed care plan.
3. What are two common examples of man- Health maintenance organizations
aged care organizations? (HMOs) and preferred provider organi-
zations (PPOs).
4. What is the typical provider network limita- They generally receive care only from
tion for individuals insured under an HMO or providers on the plan's panel.
PPO?
5. What is 'utilization review' in managed care? A process where the delivery of medical
services is scrutinized to determine if the
services are necessary.
6. Who manages Medicare-Medicaid (MC-MC) The programs are managed by individual
programs? states under federal guidelines.
7. What are the two main payment options Managed care plans (HMOs or PPOs) or
some states offer for MC-MC patients? a fee-for-service system.
8. What are Medicare Advantage Plans? Plans where the state MC-MC office con-
tracts with an HMO or PPO to provide ser-
vices, accepting the MC-MC fee schedule
for payment.
9. How does the fee-for-service system under Payments are based on specific patient
MC-MC determine hospital payments? diagnosis groups (DRGs) and codes, with
caps according to a specific schedule.
1/8
, DLM (ASCP) Exam Preparation
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10. What is the primary advantage of a Revenue for laboratory tests is based on
fee-for-service system for physician groups the volume of services provided.
regarding laboratory tests?
11. What does it mean for a physician group to The provider agrees to accept the
take an 'assignment' from Medicare-Medic- Medicare-approved amount as the total
aid? payment for covered services.
12. Under an assignment, what percentage of 80 percent.
the Medicare-approved amount is covered by
the insurance?
13. Who is responsible for the remaining 20 per- The patient.
cent of the cost when a provider accepts an
assignment?
14. Can a provider who accepts an assignment No, they cannot charge more than the
charge more than the Medicare-approved Medicare-assigned payment amount.
amount?
15. What is the maximum a physician who does Up to 15 percent above the Medicare-ap-
NOT accept an assignment can charge above proved amount.
the Medicare-approved amount?
16. If a physician does not accept an assignment, The patient is responsible for the addi-
who is responsible for the extra 15 percent tional charge on top of their regular 20
charge? percent share.
17. Do most physician groups opt for assign- Yes, a majority of physician groups opt for
ment? assignment.
18. What is the definition of a 'managed care' A generic term for various health care
system? payment systems that attempt to control
2/8
Study online at https://quizlet.com/_j950ls
1. What is the primary goal of managed care To contain costs by controlling the type,
health systems? level, and cost of services provided.
2. What is a capitation system in the context of A payment system that limits what a
managed care? health provider is paid for patient ser-
vices under a managed care plan.
3. What are two common examples of man- Health maintenance organizations
aged care organizations? (HMOs) and preferred provider organi-
zations (PPOs).
4. What is the typical provider network limita- They generally receive care only from
tion for individuals insured under an HMO or providers on the plan's panel.
PPO?
5. What is 'utilization review' in managed care? A process where the delivery of medical
services is scrutinized to determine if the
services are necessary.
6. Who manages Medicare-Medicaid (MC-MC) The programs are managed by individual
programs? states under federal guidelines.
7. What are the two main payment options Managed care plans (HMOs or PPOs) or
some states offer for MC-MC patients? a fee-for-service system.
8. What are Medicare Advantage Plans? Plans where the state MC-MC office con-
tracts with an HMO or PPO to provide ser-
vices, accepting the MC-MC fee schedule
for payment.
9. How does the fee-for-service system under Payments are based on specific patient
MC-MC determine hospital payments? diagnosis groups (DRGs) and codes, with
caps according to a specific schedule.
1/8
, DLM (ASCP) Exam Preparation
Study online at https://quizlet.com/_j950ls
10. What is the primary advantage of a Revenue for laboratory tests is based on
fee-for-service system for physician groups the volume of services provided.
regarding laboratory tests?
11. What does it mean for a physician group to The provider agrees to accept the
take an 'assignment' from Medicare-Medic- Medicare-approved amount as the total
aid? payment for covered services.
12. Under an assignment, what percentage of 80 percent.
the Medicare-approved amount is covered by
the insurance?
13. Who is responsible for the remaining 20 per- The patient.
cent of the cost when a provider accepts an
assignment?
14. Can a provider who accepts an assignment No, they cannot charge more than the
charge more than the Medicare-approved Medicare-assigned payment amount.
amount?
15. What is the maximum a physician who does Up to 15 percent above the Medicare-ap-
NOT accept an assignment can charge above proved amount.
the Medicare-approved amount?
16. If a physician does not accept an assignment, The patient is responsible for the addi-
who is responsible for the extra 15 percent tional charge on top of their regular 20
charge? percent share.
17. Do most physician groups opt for assign- Yes, a majority of physician groups opt for
ment? assignment.
18. What is the definition of a 'managed care' A generic term for various health care
system? payment systems that attempt to control
2/8
