Basics of the U.S. Health Care System Chapter 9 Exam Questions with
Correct Solutions and Answers with Verified Solutions | Latest 2026
Update
, Q: Concurrent Utilization Review Decisions are made during course of service such
as length of
Answer:
inpatient stay and additional surgery
Retrospective Utilization Review An evaluation of services once services have been
provided. May occur to assess treatment patterns of certain diseases. May include a
financial
review to assure accuracy of billing.
Practice Profiling Examines specific provider patterns of practice, a type of
retrospective
utilization review, also a type of employee performance review because focus is to
determine
which provider fits in with organizational culture of MCO
Risk plans Pay a premium per member based on the member's county of residence,
members can use both in-network and out-of-network providers, covers all Medicare
services,
vision and prescription care.
Medicare cost plans A type of HMO, has similar rules to Medicare Advantage plans.
CMS
reimburses MCOs on a preset monthly basis per enrollee based on a forecasted
budget.
Reimbursement is based on reasonable cost of providing services, allow members to
pursue
care outside network, if this occurs services are covered under original Medicare.
Correct Solutions and Answers with Verified Solutions | Latest 2026
Update
, Q: Concurrent Utilization Review Decisions are made during course of service such
as length of
Answer:
inpatient stay and additional surgery
Retrospective Utilization Review An evaluation of services once services have been
provided. May occur to assess treatment patterns of certain diseases. May include a
financial
review to assure accuracy of billing.
Practice Profiling Examines specific provider patterns of practice, a type of
retrospective
utilization review, also a type of employee performance review because focus is to
determine
which provider fits in with organizational culture of MCO
Risk plans Pay a premium per member based on the member's county of residence,
members can use both in-network and out-of-network providers, covers all Medicare
services,
vision and prescription care.
Medicare cost plans A type of HMO, has similar rules to Medicare Advantage plans.
CMS
reimburses MCOs on a preset monthly basis per enrollee based on a forecasted
budget.
Reimbursement is based on reasonable cost of providing services, allow members to
pursue
care outside network, if this occurs services are covered under original Medicare.
