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PHLT 313 Exam 3 QUESTIONS WITH CORRECT ANSWERS
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PHLT 313 Exam 3 QUESTIONS WITH CORRECT ANSWERS
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PHLT 313 Exam 3 QUESTIONS WITHCORRECT ANSWERS
MCOs manage - CORRECT ANSWER-- Financing
- Insurance
- Delivery
- Payment
MCOs exercise formal control over the utilization of - CORRECT ANSWER-Health Care Services
The most common methods used for reimbursing providers are: - CORRECT ANSWER-- Capitation
- Discounted fees
- Salaries
Capitation - CORRECT ANSWER-- The provider is paid a fixed monthly sum per enrollee
- Often called a per member, per month (PMPM) payment
Discounted Fees - CORRECT ANSWER-- A modified form of fee-for-service
- Discounts are offered in exchange for a certain volume of business
Salaries - CORRECT ANSWER-Generally combined with bonuses for efficiency
Accreditation measures - CORRECT ANSWER-Performance
Accreditation and Quality Organizations - CORRECT ANSWER-- National Committee for Quality Assurance
(NCQA)
- The Centers for Medicare and Medicaid Services (CMS)
Early 1900s
PHLT 313 Exam 3 QUESTIONS WITH CORRECT ANSWERS
,(Evolution and Growth of Managed Care) - CORRECT ANSWER-Railroad, mining, and lumber companies
1929
(Evolution and Growth of Managed Care) - CORRECT ANSWER-- First private health insurance plan
- Baylor University Hospital
- Provided teachers with a certain number of hospital stays
1940s
(Evolution and Growth of Managed Care) - CORRECT ANSWER-Large health plans emerged in the US
1973
(Evolution and Growth of Managed Care) - CORRECT ANSWER-The Health Maintenance Organization Act
1980s
(Evolution and Growth of Managed Care) - CORRECT ANSWER-- Slow growth, but health care costs
continued to rise
- Creation of other forms of managed care
Managed Care today is... - CORRECT ANSWER-Different than the original form
Managed Care 1990s - CORRECT ANSWER-- Limited number of providers
- Control over utilization and limits on reimbursement
Managed Care compromise today - CORRECT ANSWER-- Utilization management was relaxed
- Multiple reimbursement method
- Increase provider choice
3 Main Types of Utilization Controls - CORRECT ANSWER-- Expert evaluation
- Determination of least expensive service
PHLT 313 Exam 3 QUESTIONS WITH CORRECT ANSWERS
,- Review the course of medical treatment
Gatekeeping - CORRECT ANSWER-- Commonly used by HMOs
- Primary Care Provider (PCP) coordinate all health services
- Emphasizes preventative care, routine physical examinations, and other primary care services
- Make referral for specialty services
Utilization Review - CORRECT ANSWER-Evaluates services provided to make sure patient is receiving
adequate care with little waste
3 Types of Utilization Control Methods - CORRECT ANSWER-- Prospective
- Concurrent
- Retrospective
Prospective Utilization Review - CORRECT ANSWER-Review of course of treatment before the care is
actually delivered
Concurrent Utilization Review - CORRECT ANSWER-Review of course of treatment during the health care
utilization
Retrospective Utilization Review - CORRECT ANSWER-Review of course of treatment after the care is
delivered
3 Types of Managed Care Plans - CORRECT ANSWER-- HMO plans
- PPO plans
- POS plans
HMO Plans - CORRECT ANSWER-- First type of managed care plans on the market
- Focus on wellness care
- Utilize gatekeepers
PHLT 313 Exam 3 QUESTIONS WITH CORRECT ANSWERS
, PPO Plans - CORRECT ANSWER-- Offer out-of-network option for enrollees
- Higher copayments apply for using non-preferred providers
- Use discounted fee arrangements with providers
- Do not use gatekeeper in most cases
POS Plans - CORRECT ANSWER-- POS plan combine HMO and PPO
- POS plans overcome restricted provider choice but retain the benefits of tight utilization
- Free choice of providers is a major selling point for POS
- High out of pocket expenses
Managed Care Influence on Cost Containment - CORRECT ANSWER-- Control by private section
- Control by government
- Ability to control costs
- Premium increases
Managed Care Impact of Access - CORRECT ANSWER-- Access to primary care, preventive services, and
health promotion activities
- Fewer disparities
- ER and specialists usage
Managed Care Influence on Quality of Care - CORRECT ANSWER-- HMO v. non-HMO
- Race, ethnicity, and socioeconomic status
Integrated Systems - CORRECT ANSWER-Growing power of managed care
Purpose of Integration - CORRECT ANSWER-- Cost reduction
- Survival
- Mergers and acquisitions
PHLT 313 Exam 3 QUESTIONS WITH CORRECT ANSWERS
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