Giant ACO has agreed to a shared savings rate of 65 percent and a shared loss rate of 40percent with CMS. Giant ACO participates in a __________ risk agreement.

      1. Evie is enrolled in Medicare Parts A and B. She recently started PT for hip pain. The approved amount per visit is $125. How much does Evie owe in cost sharing per visits. Evie has already met her outpatient deductible. (Blank 1) 2. Clyde is enrolled in Medicare Parts A and B. He had a knee arthroscopy in January. This is Clyde’s first health encounter for the year so he has not met his deductible. The approved amount for his surgeon is $550. How much does Clyde owe in cost sharing for the surgeon’s services. (Blank 2)

Which of the following statements about retrospective reimbursement is false?

Medicaid is a joint program between _________and _________governments?

One managed care concept that has carried over to most insurance plans is utilization management. A key component of utilization management is utilization review. Describe utilization review. Provide an example of when utilization review would be used.

Which of the following is not a limitation typically included in a health insurance policy?

Use the following excerpt from table 3.2, Part B Services 2020 1. Alona is enrolled in Medicare Parts A and B. She goes to the hospital seniors clinic for her arthritis. She had a regular visit in June when Dr. Proudfoot examined her, checked her medications, and suggested water aerobics. The approved amount for her visit is $230. Alona met her outpatient deductible in March. What is her cost sharing amount for the visit to Dr. Proudfoot? (Blank 1) 2. Sal is enrolled in Medicare Parts A and B. He goes to the hospital seniors clinic for congestive heart failure. He had a regular visit in November when Dr. Nauman examined him, checked his medications, and suggested a high fiber diet. The approved amount for her visit is $275. Sal met his outpatient deductible in February. What is his cost sharing amount for the visit to Dr. Nauman?

Which of the following is not a principle of revenue integrity?

Medicare has four criteria to define medically necessary services. Which of the following is not one of the four criteria?

Managed care plans control beneficiary choice of provider. On the continuum of control, which type of managed care organization has the most control and, therefore, has the greatest limitations on a beneficiary seeing a provider that is not in-network?