Healthcare Reimbursement Ch. 5
Practice Questions and Correct Answers
Capitation ✅Method of payment for health services in which an individual or
institutional provider is paid a fixed, per capita amount for each person enrolled without
regard to the actual number or nature of services provided or number of persons
served.
Carve-out ✅Contracts that separate out services or populations of patients or clients to
decrease risks and costs.
Case management ✅Coordination of individuals' care over time and across multiple
sites and providers, especially in complex and high-cost cases. Goals include continuity
of care, cost-effective Ness, quality, and appropriate utilization.
Cherry-picking ✅Targeting the enrollment of healthy patients to minimize healthcare
costs.
Closed panel ✅Type of health maintenance organization that provides hospitalization
and physicians' services through its own staff and facilities.
Community rating ✅Method of determining health care premium rates by geographic
area rather than by age, health status, or Company size. This method increases the
size of the risk pool. Costs are increased two younger, healthier individuals who are, in
effect, subsidizing older or less healthy individuals.
Disease management ✅Program focused on preventing exacerbation of chronic
diseases and on promoting healthier lifestyles for patients and clients with chronic
diseases.
Dual eligible ✅Person who qualifies for both Medicare and Medicaid.
Enrollee ✅Covered member or covered member's dependent of a health maintenance
organization.
Episode-of-care reimbursement ✅Healthcare payment method in which providers
receive one lump sum for all care they provide related to a condition or disease.
Evidence-based clinical practice guidelines ✅Explicit statement that guides clinical
decision making and has been systematically developed from scientific evidence and
clinical expertise to answer clinical questions.
Practice Questions and Correct Answers
Capitation ✅Method of payment for health services in which an individual or
institutional provider is paid a fixed, per capita amount for each person enrolled without
regard to the actual number or nature of services provided or number of persons
served.
Carve-out ✅Contracts that separate out services or populations of patients or clients to
decrease risks and costs.
Case management ✅Coordination of individuals' care over time and across multiple
sites and providers, especially in complex and high-cost cases. Goals include continuity
of care, cost-effective Ness, quality, and appropriate utilization.
Cherry-picking ✅Targeting the enrollment of healthy patients to minimize healthcare
costs.
Closed panel ✅Type of health maintenance organization that provides hospitalization
and physicians' services through its own staff and facilities.
Community rating ✅Method of determining health care premium rates by geographic
area rather than by age, health status, or Company size. This method increases the
size of the risk pool. Costs are increased two younger, healthier individuals who are, in
effect, subsidizing older or less healthy individuals.
Disease management ✅Program focused on preventing exacerbation of chronic
diseases and on promoting healthier lifestyles for patients and clients with chronic
diseases.
Dual eligible ✅Person who qualifies for both Medicare and Medicaid.
Enrollee ✅Covered member or covered member's dependent of a health maintenance
organization.
Episode-of-care reimbursement ✅Healthcare payment method in which providers
receive one lump sum for all care they provide related to a condition or disease.
Evidence-based clinical practice guidelines ✅Explicit statement that guides clinical
decision making and has been systematically developed from scientific evidence and
clinical expertise to answer clinical questions.
