Steps used to control costs of managed care include: - ANSWER-Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used
... [Show More] 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, EXCEPT: - ANSWER-Ties to the healthcare delivery industry rather than the insurance industry
Provider service organizations (PSOs) function like health maintenance organizations (HMOs) in all of the following ways: - ANSWER--Risk pooling
-Capitalization
-Network management
Which of the following is a service provided by a well-managed third-party administrator (TPA)? - ANSWER--Administrative
-Utilization review (UR)
-Claims processing
What is tiering? - ANSWER-The ranking or classifying of one or more of the provider delivery system components
Which option is a practice used to control costs of managed care? - ANSWER--Making advance payment to providers for all services needed to care for a member
-Combining services provided and bundling the associated charges
-Agreement between the payer and provider on reasonable payment for each service.
Which option is a risk involved in per diem payments? - ANSWER--The risk to the insurance company or health plan
-The risk to the hospital
-The risk when embracing per diem payments in complex case
Diagnosis-related group (DRG) is: - ANSWER-A payment category
How is the term carve-out used when discussing managed care? - ANSWER-To refer to specific benefits or services
What is the term Coordination of Benefits (COB)? - ANSWER-A term used to describe how payment is coordinated for patients who have coverage through two insurance policies
Which three components are used to determine the total RVU value for a service? - ANSWER--Malpractice expense
-Lowest market price for services used
-Medicare discounts
A fixed payment amount based upon the number of members assigned to a provider, and does not vary based upon the number of services rendered, is known as: - ANSWER-Capitation
Aligning incentives has come to mean _________. - ANSWER-The appropriate addition of some risk in the exchange of health care to a patient for some form of remuneration.
According to MedPAC, which option is a benefit or undesirable consequence of bundling
payments? - ANSWER--It allows Medicare to pay a set fee per hospitalization episode.
-It would provide the potential to improve efficiency and quality
-It would lead to underutilization of services
As the healthcare industry moves to control growth in medical spending, what initiative can help hospitals maintain their margins? - ANSWER-Contract standardization
As the healthcare industry moves to control growth in medical spending, what initiative can NOT help hospitals maintain their margins? - ANSWER--Pay-for-performance programs
-Health savings accounts
-Price transparency
Identify which initiatives are focused on in an effort to help increase an organization's revenue/profit /margins. - ANSWER--Health plan consolidation
-Payment policing and standardization of contract requirements
-Shift in volume and cost risk to hospitals
-Contract performance modeling
What are rating tiers? - ANSWER-Different rates charged on the basis of the number and relationships
What is the role of reinsurance? - ANSWER-Reinsurance seeks to limit a policyholder's liability for catastrophic claims
Which option is a major trend in case management? - ANSWER--Shift from broad-based toward more focused efforts
-Reduction of administrative costs
-Greater physician involvement
What type of provider authorization is applied in emergency cases, where prior authorization is impossible? - ANSWER-Concurrent
What is utilization management (UM)? - ANSWER-A tool to control the costs of providing healthcare services to enrollees
Which of the following statements is true about disease management (DM)? - ANSWER-DM programs encourage patients to assume some control over their disease state
What is the function of catastrophic case management (CM)? - ANSWER-It is used to manage diseases in patients with very high costs of care.
What is demand management? - ANSWER-A coordinated effort by the MCO, employers, and providers to control the utilization of medical services and resources
All of the following are effective contract evaluation criteria, EXCEPT: - ANSWER-Detailed contract performance assessments
All of the following are effective contract evaluation criteria: - ANSWER--General payer or provider criteria
-Reimbursement levels and parameters
-Provider costs and responsibilities
The following are tools for optimizing contract performance, EXCEPT: - ANSWER-Contract language
The following are tools for optimizing contract performance: - ANSWER--Financial and volume analysis models.
-Managed care contract dashboard.
-Detailed contract performance assessments.
Which option is considered a key difference between inpatient and outpatient contracting? - ANSWER--Reimbursement methodology differences
-Operational policies and procedures
-Market differences affecting outpatient and inpatient volumes
All of the following should be analyzed prior to and/or during contract negotiations, EXCEPT: - ANSWER-Historical member premiums
All of the following should be analyzed prior to and/or during contract negotiations: - ANSWER--Member volumes by product type
-Historical reimbursement levels by product type
-Historical claims payment and/or submission problems
What is a clean claim? - ANSWER-A properly completed billing form
Which data is included in a termination provision in standard contracting? - ANSWER--What is cause?
-What is termination Without Cause?
-Notice of termination
What is direct contracting? - ANSWER-A single-employer or multi-employer healthcare alliances that contract directly with providers for healthcare services
What is a non-directed PPO? - ANSWER-A payer that has contracted either directly or indirectly with the provider to access preferred rates
All of the following are responsibilities of a provider organization's Board of Directors, EXCEPT: - ANSWER-Implementation issues
All of the following are responsibilities of a provider organization's Board of Directors: - ANSWER--Fiduciary matters
-Legal affairs
-Policy matters
Which of the following is required for claims processing? - ANSWER--Patient and/or enrollee ID, age, and gender
-Type of diagnosis/major diagnostic category
-Date of service
Which of the following terms refers to information about any other health plan or carrier that may share liability for healthcare expenses via a spouse's coverage or the like? - ANSWER-Coordination of benefits (COB)
What is the function of electronic data interchange (EDI)? - ANSWER-To allow both healthcare providers and payers to exchange common information required
What was the aim of advocacy groups initiated in the late 1990s? - ANSWER-To inform the discussion about the quality of care and the value of benefit plans
Which of the following statements is true regarding The Leapfrog Group? - ANSWER-The Leapfrog Group was started in the late 1990s to engage consumers and clinicians in the discussion to improve care quality.
Which option is included in the set of new value propositions and tools that emerged in the early 2000s? - ANSWER--Product development focused on employee contribution strategies, network access, and funding options.
-Medical management philosophies based on retrospective evaluation of care, rather than prospective review and management.
-A proliferation of self-service technologies to reduce administrative costs.
Identify which option(s) is a benefit for CDHP consumers. - ANSWER--Coverage
-Choice
-Access
Identify which options are a benefit for HSA consumers. - ANSWER--It is transportable, allowing workers access from one job to the next.
-Both employees and employers can contribute pretax dollars to the qualified account.
-They are available to everyone, not just employees of small businesses or the self-
employed.
What is an ACO? - ANSWER-A system of providers and facilities that can work in concert to care for a given patient population
What is the purpose of the comprehension accreditation process? - ANSWER-To evaluate an organization's compliance with the CMS COP standards and other accreditation requirements
What was the aim of the HMO Act of 1973? - ANSWER-To change the system of health care delivery.
To be eligible for COBRA coverage, an employee must have: - ANSWER-Been enrolled in an employer's health plan while working and the health plan must continue to be in effect for active employees.
What is the purpose of Consolidated Omnibus Budget Reconciliation Act (COBRA) legislation? - ANSWER-To provide continuation of group health coverage that otherwise might be terminated
What is one purpose of the Emergency Medical Treatment and Active Labor Act (EMTALA)? - ANSWER-To govern when and how a patient presenting at a hospital may be refused treatment
What is the purpose of the URAC? - ANSWER-To promote healthcare quality through accreditation and certification programs
Which options are a focus of the HIPAA Title II series of laws? - ANSWER--Health care access, portability, and renewability
-To maintain the efficiency and effectiveness of the electronic transmission of health information.
-Health care claim professional (837P), health care claim dental (837D), and health care claim payment/advice (835)
What was the expectation of the 2010 Patient Protection and Affordable Care Act (PPACA)? - ANSWER-To bring coverage to millions of Americans who could not or would not purchase health insurance
What is Managed Care? - ANSWER-Managed care organizations (MCO) exist primarily in four forms:
-Health Maintenance Organizations (HMO)
-Preferred Provider Organizations (PPO)
-Point of Service (POS) Organizations
-Exclusive Provider Organizations (EPO)
HMO Act 1973 - ANSWER--The original HMO Act was designed to create new physician groups that would act as
prepaid practice groups (PPGs).
-HMO concept was to create a seamless integration of comprehensive care delivery with a
financing mechanism for benefits. These benefit plans would remove most deductibles and
copays, and also cover preventive services that were previously excluded by all insurers
Effects of the HMO Act - ANSWER--The new law 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 by section 1310 of the HMO Act to make a dual choice available to their employees. This meant that employees would have a choice to select one or more HMOs or select the employer's traditional insurance plan.
Early Growth and Development of Managed Care - ANSWER--Managed care significantly predates the 1973 HMO Act.
-Employers deducted a share of the workers' salary as payment for these services as well
as funding a pool for what we would now call worker compensation and disability
payment funds.
Health Maintenance Organizations (HMO) - ANSWER--Referralso 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)
Preferred Provider Organizations (PPO) - ANSWER--No referrals
-No PCP
-Reimbursement - discounted fee-for-service based model, where providers are contractually obligated to provide covered persons with specific services at discounted rates. This may also be accompanied by a utilization review mechanism embedded in the contract to manage costs over time.
Point of Service (POS) Organizations - ANSWER--No referrals
-PCP
-Combine features of both an HMO and PPO
-A covered individual is required to have a primary care provider but can also self-
refer to other in-network specialists as needed
Exclusive Provider Organizations (EPO) - ANSWER--No referral
-No PCP [Show Less]