BU.881.704
Providers & Payers
Finals Exam Review (Qns & Ans)
2025
1. Which of the following is a key financial relationship between
providers and payers in healthcare?
- A. Profit-sharing agreements
- B. Claims submission and reimbursement
- C. Employment contracts
- D. Investment partnerships
Correct ANS: B. Claims submission and reimbursement
Rationale: Providers submit claims to payers to receive
reimbursement for services rendered, forming the backbone of
their financial interaction.
©2025
,2. A "capitation" payment model implies:
- A. Providers are paid a fixed fee per patient, regardless of
services rendered
- B. Providers are reimbursed per service provided
- C. Patients pay directly for services at the point of care
- D. Payers distribute revenue based on the provider's
performance
Correct ANS: A. Providers are paid a fixed fee per patient,
regardless of services rendered
Rationale: Capitation incentivizes cost efficiency as
providers must manage care within a fixed budget per patient.
3. Which regulatory body monitors payer-provider contractual
disputes in the U.S.?
- A. Centers for Medicare & Medicaid Services (CMS)
- B. Federal Trade Commission (FTC)
- C. National Labor Relations Board (NLRB)
- D. Securities and Exchange Commission (SEC)
Correct ANS: B. Federal Trade Commission (FTC)
Rationale: The FTC oversees practices to prevent
anticompetitive conduct in payer-provider relationships.
©2025
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Fill-in-the-Blank Questions
4. The __________ model allows providers to earn additional
payments for meeting certain quality benchmarks.
Correct ANS: Pay-for-performance (P4P)
Rationale: Pay-for-performance rewards providers for
meeting pre-established quality or efficiency goals.
5. The term __________ refers to a payment arrangement where
providers bear the financial risk for delivering care under a fixed
budget.
Correct ANS: Risk-based contracting
Rationale: Risk-based contracting shifts financial
accountability to providers for patient outcomes.
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True/False Questions
6. Providers within a Health Maintenance Organization (HMO)
network are prohibited from offering services to non-HMO
members.
©2025
, Correct ANS: True
Rationale: HMOs typically operate with exclusive networks,
ensuring patients only receive in-network care.
7. Fee-for-service payment models inherently discourage
unnecessary diagnostic testing.
Correct ANS: False
Rationale: Fee-for-service models can incentivize providers
to order more tests to increase reimbursement.
---
Multiple Response Questions
8. Select the payment models commonly used in payer-provider
arrangements: (Choose all that apply)
- A. Value-based payments
- B. Bundled payments
- C. Pay-as-you-go schemes
- D. Capitation
Correct ANSs: A, B, D
©2025
Providers & Payers
Finals Exam Review (Qns & Ans)
2025
1. Which of the following is a key financial relationship between
providers and payers in healthcare?
- A. Profit-sharing agreements
- B. Claims submission and reimbursement
- C. Employment contracts
- D. Investment partnerships
Correct ANS: B. Claims submission and reimbursement
Rationale: Providers submit claims to payers to receive
reimbursement for services rendered, forming the backbone of
their financial interaction.
©2025
,2. A "capitation" payment model implies:
- A. Providers are paid a fixed fee per patient, regardless of
services rendered
- B. Providers are reimbursed per service provided
- C. Patients pay directly for services at the point of care
- D. Payers distribute revenue based on the provider's
performance
Correct ANS: A. Providers are paid a fixed fee per patient,
regardless of services rendered
Rationale: Capitation incentivizes cost efficiency as
providers must manage care within a fixed budget per patient.
3. Which regulatory body monitors payer-provider contractual
disputes in the U.S.?
- A. Centers for Medicare & Medicaid Services (CMS)
- B. Federal Trade Commission (FTC)
- C. National Labor Relations Board (NLRB)
- D. Securities and Exchange Commission (SEC)
Correct ANS: B. Federal Trade Commission (FTC)
Rationale: The FTC oversees practices to prevent
anticompetitive conduct in payer-provider relationships.
©2025
,---
Fill-in-the-Blank Questions
4. The __________ model allows providers to earn additional
payments for meeting certain quality benchmarks.
Correct ANS: Pay-for-performance (P4P)
Rationale: Pay-for-performance rewards providers for
meeting pre-established quality or efficiency goals.
5. The term __________ refers to a payment arrangement where
providers bear the financial risk for delivering care under a fixed
budget.
Correct ANS: Risk-based contracting
Rationale: Risk-based contracting shifts financial
accountability to providers for patient outcomes.
---
True/False Questions
6. Providers within a Health Maintenance Organization (HMO)
network are prohibited from offering services to non-HMO
members.
©2025
, Correct ANS: True
Rationale: HMOs typically operate with exclusive networks,
ensuring patients only receive in-network care.
7. Fee-for-service payment models inherently discourage
unnecessary diagnostic testing.
Correct ANS: False
Rationale: Fee-for-service models can incentivize providers
to order more tests to increase reimbursement.
---
Multiple Response Questions
8. Select the payment models commonly used in payer-provider
arrangements: (Choose all that apply)
- A. Value-based payments
- B. Bundled payments
- C. Pay-as-you-go schemes
- D. Capitation
Correct ANSs: A, B, D
©2025
