Chapter 17 Other Health Plans
Preferred provider organization (PPO)
-HMO allows subscribers to use providers outside of the HMO -No gate keeper for out of network services -subscribers pay more of the cost -called open-ended HMO
Point of service
-HMO allows subscribers to use providers outside of the HMO -no gate keeper for out of network services -subscribers pay more of the cost -called open-ended HMO
Features of HMOs
-managed care -prepaid services -co-pays -gatekeeper (primary care physician) -limited choice of providers -limited service area
Cost Containment- managed care
-preventive care -reducing Hospital care costs *outpatient benefits **second surgical opinion **preauthorization-precertification **limits on lengths of stay -alternatives to hospital care **skilled nursing facilities **intermediate nursing facilities **rehabilitative facilities *home health care -utilization management **prospective review **concurrent review **retrospective review
all of the following statements about an HMO are correct EXCEPT
HMO's operate on a fee for service plan
The main difference between traditional health insurance arrangements and HMOs is that
HMOs provide both the health care serve and the health care financing, but traditional health care insurance companies provide only the financing
all of the following are characteristics of a PPO EXCEPT
PPO's operate on a prepaid basis
If treatment requiring hospitalization is recommended, the physician of the insured may have to get the expense approved prior to obtaining the treatment. This is known as
Preauthorization
What is an HMO known for?
Preventative care
all of the following are points in the process of utilization management EXCEPT
alternative review
Gwyneth's HMO requires that she receive health care services from a specified, limited number of health care providers chosen by the HMO. Gwyneth's HMO is
closed panel
all of the following are examples of managed care plans EXCEPT
indemnity arrangements
Which of the following alternatives to hospital care provides intermittent nursing care for patients who do not need 24 hour supervision?
intermediate nursing facility
all of the following are features of HMO's EXCEPT
medical services are provided first, and then they are billed and paid for
David has a PPO that does not limit him to use only providers that have contracts with the PPO. David's PPO is
open panel
PPO subscribers are not strictly limited to using providers that have contracts with the PPO.
open-panel entities
a type of HMO that does not have a gatekeeper and allows subscribers to obtain care from either providers that do or not belong to the HMO is called a
point of service plan
Which utilization management review is done after the treatment is complete?
retrospective review
Which of the following cost saving measures allows or requires insureds to consult a doctor other than their attending physician to see if an alternative method of treatment would be desirable?
second surgical opinion
All of the following are alternatives to hospital care EXCEPT
utilization management