WGU C425 COMPLETE QUESTION SET
100% CORRECT ANSWERS AND
SOLUTIONS
◉ MCOs
Answer: garnered enormous buyhing power by enrolling a large
segment of the insured population and taking responsibility to
procedure cost effective health care for enrollees
◉ Managed care
Answer: mechanism for providing health care services where a
single organization takes on the management of financing,
insurance, delivery, payment
◉ capitiaiton
Answer: the provider is paid a fixed monthly sum per enrollee
often called per member per month PMPM
◉ discounted fees
Answer: a modified form of fee for service
◉ MCOS
Answer: accredited by the national committee for quality
assurance
, NCQA
◉ HEDIS data
Answer: incorporate a number of different measures on cost and
quality amounts off the regular fees often range between 25-35%
◉ What are the 3 jobs of MCOs
Answer: Expert evaluation of what services are medically
necessary.
Determination of how services can be provided most
inexpensively (e.g., outpatient vs inpatient).
Review the course of medical treatment (e.g., when a patient is in
the hospital).
◉ utilization review
Answer: process of evaluating the appropriateness of services
provided
◉ prospective utilization review
Answer: the medical necessity for certain treatments is
determined before the care is delivered-prevent unnecessary
treatments
◉ retrospective utilization review
100% CORRECT ANSWERS AND
SOLUTIONS
◉ MCOs
Answer: garnered enormous buyhing power by enrolling a large
segment of the insured population and taking responsibility to
procedure cost effective health care for enrollees
◉ Managed care
Answer: mechanism for providing health care services where a
single organization takes on the management of financing,
insurance, delivery, payment
◉ capitiaiton
Answer: the provider is paid a fixed monthly sum per enrollee
often called per member per month PMPM
◉ discounted fees
Answer: a modified form of fee for service
◉ MCOS
Answer: accredited by the national committee for quality
assurance
, NCQA
◉ HEDIS data
Answer: incorporate a number of different measures on cost and
quality amounts off the regular fees often range between 25-35%
◉ What are the 3 jobs of MCOs
Answer: Expert evaluation of what services are medically
necessary.
Determination of how services can be provided most
inexpensively (e.g., outpatient vs inpatient).
Review the course of medical treatment (e.g., when a patient is in
the hospital).
◉ utilization review
Answer: process of evaluating the appropriateness of services
provided
◉ prospective utilization review
Answer: the medical necessity for certain treatments is
determined before the care is delivered-prevent unnecessary
treatments
◉ retrospective utilization review
