Steps used to control costs of managed care include: - ANSWER-
Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - ANSWER-Inpatient admissions for the
purpose of reimbursing hospitals for each case in a given category
w/a negotiated fixed fee, regardless of the actual costs incurred
Identify the various types of private health plan coverage - ANSWER-
HMO
Conventional
PPO and POS
HDHP/SO plans - high-deductible health plans with a savings option;
Private - Include higher patient out-of-pocket expenditures for
treatments that can serve to reduce utilization/costs.
Managed care organizations (MCO) exist primarily in four forms: -
ANSWER-Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
,Identify the various types of government‐sponsored health coverage:
- ANSWER-Medicare - Government; Beneficiaries enrolled in such
plans, but, participation in these plans is voluntary.
Medicaid
Medicaid Managed Care - Medicaid beneficiaries are required to select
and enroll in a managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
Identify some key drivers of increasing healthcare costs - ANSWER-
Demographics
Chronic Conditions
Provider payment systems - Provider payment systems that are
designed to reward volume rather than quality, outcomes, and
prevention
Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
Health Maintenance Organizations (HMO) - ANSWER-Referrals
PCP
Patients must use an in-network provider for their services to be
covered.
Reimbursement - majority of services offered are reimbursed through
capitation payments (PMPM)
,Medicare is composed of four parts: - ANSWER-Part A - provides
inpatient/hospital, hospice, and skilled nursing coverage
Part B - provides outpatient/medical coverage
Part C - an alternative way to receive your Medicare benefits (known
as Medicare
Advantage)
Part D - prescription drug coverage
HMO Act of 1973 - ANSWER-The HMO Act of 1973 gave federally
qualified HMOs the right to mandate that employers offer their
product to their employees under certain conditions. Mandating an
employer meant that employers who had 25 or more employees and
were for‐profit companies were required to make a dual choice
available to their employees.
Which of the following statements regarding employer-based health
insurance in the United States is true? - ANSWER-The real advent of
employer-based insurance came through Blue Cross, which was
started by hospital associations during the Depression.
The Health Maintenance Organization (HMO) Act of 1973 gave
qualified HMOs the right to "mandate" an employer under certain
conditions, meaning employers: - ANSWER-Would have to offer HMO
plans along side traditional fee-for-service medical plans.
Which of the following is an anticipated change in the relationships
between consumers and providers? - ANSWER-Providers will face
, many new service demands and consumers will have virtually
unfettered access to those services
What transition began as a result of the March 2010 healthcare reform
legislation? - ANSWER-A transition toward new models of health care
delivery with corresponding changes system financing and provider
reimbursement.
Which statement is false concerning ABNs? - ANSWER-ABN began
establishing new requirements for managed care plans participating
in the Medicare program.
Which Statement is TRUE concerning ABNs? - ANSWER--ABNs are
not required for services that are never covered by Medicare. -An ABN
form notifies the patient before he or she receives the service that it
may not be covered by Medicare and that he or she will need to pay
out of pocket. -Although ABNs can have significant financial
implications for the physician, they also serve an important fraud and
abuse compliance function.
What is the overall function of Medicaid? - ANSWER-The pay for
medical assistance for certain individuals and low-income families
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: -
ANSWER-Total Medical Expenses divided by Total Premiums
Provider service organizations (PSOs) function like health
maintenance organizations (HMOs) in all of the following ways,
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