Unit 17 - Other Health Plans
To control costs, medical insurance plans available from commercial insurers and fraternal organizations are likely to provide care through
AN OPEN-NETWORK PPO Many commercial insurers and fraternal contract with independent physician groups and hospitals, creating extensive, often loosely organized preferred provider organizations for their insureds. Insureds are given lists of approved providers in their areas. Insureds have the option to go outside the system. However, reimbursements are higher when they use approved providers who are contracted at reduced rates.
Which of the following is the best reason why a medical plan would require a concurrent review for hospital patients?
QUALITY CARE IS ENSURED AT THE MOST REASONABLE EXPENSE Concurrent review is a medical decision attempting to ensure the the hospital stay is as short as possible, yet still appropriate for the patient's medical condition. Providers may consult with other providers to discuss alternatives, such as home health care or hospice care.
All of the following are basic health care services offered by HMOs EXCEPT
REHABILITATIVE AND HOME HEALTH SERVICES Basic health care services include emergency care, inpatient hospital and physician care, outpatient medical and chiropractic services, laboratory and x-ray services, coverage for certain low-protein food products, optional coverage for mental health services for alcohol or drug abuse, and chiropractic services on a referral basis as an optional service. Rehabilitative and home health services are not considered basic health care services; instead, they are characterized as health care services.
Traditional indemnity plans are characterized by all of the following EXCEPT
THE ABILTY TO ACCESS CARE FORM A SPECIALIST ONLY WITH A REFERRAL FROM A PRIMARY CARE PHYSICIAN Traditional indemnity plans provide access to any willing health care provider. Commercial insurance indemnity plans are structured on a fee-for-service basis with no requirement that a primary care physician manage care for the insured.
Which of the following statements about preferred provider organizations is NOT correct?
THEY OFFER HEATLH CARE COVERAGE TO LOW-INCOME INDIVIDUALS A PPO (preferred provider organization) is similar to an HMO, but members pay for services as they are provided at rates that have been discounted in advance for the PPO. Physicians offering their services through a PPO are in private practice. PPOs are not insurers and, thus, do not offer health care coverage.
A point-of-service (POS) plan is most like a health maintenance organization (HMO) in which of the following ways?
BOTH USE A PRIMARY CARE PHYSICIAN POS plans and HMOs both use primary care physicians as gatekeepers to provide cost control. Members of an HMO can generally not use health care providers outside the organization. An HMO has employees, while aPOS generally contracts with independent providers. HMOS are generally nonprofit, while POS plans are for-profit.
What is the name of the fixed monthly fee paid by the HMO to the provider?
CAPITATION In addition to the co-pay paid by the provider, the HMO pays a fixed monthly fee to the provider based on the number of HMO subscribers, without consideration for the number of subscriber visits or services provided.
HMOs may provide supplemental health care services. WHIch of the following is NOT a supplemental health care service?
OUTPATIENT CARE HMOs may, at their option, provide certain supplemental health care services for a fee. These include dental care, substance abuse care, vision care, and home health care. Outpatient care is a basic health care service required by law.
HMOs may provide supplemental health care services. Which of the following is NOT a supplemental health care service?
OUTPATIENT CARE HMOs may, at their option, provide certain supplemental health care services for a feee. These include dental care, substance abuse care, vision care, and home health care. Outpatient care is a basic health care service required by law.
Under what system do a group of doctors and hospitals in a designated area contract with an insurer to provide medical services at a prearranged cost to the insured?
PPO Preferred provider organizations (PPOs) are groups of doctors and hospitals that contract with an insurer to provide medical services at a prearranged cost, thus allowing insureds to choose among these groups.
All of the following are types of utilization management EXCEPT
PREAUTHORIZATION REVIEW Utilization management places oversight on medical care to make sure it is appropriate and effective. Those reviews can be prospective, concurrents and retrospective.
Traditional indemnity plans are characterized by all of the following EXCEPT
THE ABILITY TO ACCESS CARE FROM A SPECIALIST ONLY WITH A REFERRAL FROM A PRIMARY CARE PHYSICIAN Traditional indemnity plans provide access to any willing health care provider. Com Mercia insurance indemnity plans are structured on a fee-for-service basis with no requirement that a primary care physician manage care for the insured.
Which of the following statements regarding persons participating in an HMO is CORRECT?
THEY PAY A FIXED PERIODIC FEE WHETHER OR NOT HEALTH CARE SERVICES ARE USED Persons participating in an HMO pay a fixed periodic fee in advance for services performed by participating physicians and hospitals. This fee is payable, whether or not the participant uses any health care services.
Which of the following is a goal of managed care plans?
TO APPLY FINANCIAL INCENTIVES THAT REDUCE THE QUANTITY AND COST OF SERVICES Managed care plans, such as HMOs, PPOs, and POS plans, offer comprehensive medical services to their members. They also apply financial incentives that encourage providers to keep both the quantity and cost of services in check and motivate members to select cost-effective providers.
A formal technique designed to evaluate the clinical necessity, appropriateness, or efficiency of health care services, procedures, or settings is known as
UTILIZATION REVIEW Utilization review is a set of techniques designed to evaluate the clinical necessity of health care services. Techniques include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, and retrospective review.
According to federal law, HMO basic health care services include all of the following EXCEPT
VISION CARE SERVICES The HMO Act of 1973 specified requirements that must be met for an HMO to receive federal qualification. For example, federally qualified HMOs must provide basic health care services and charge a community rate. Basic health care services include physician services; inpatient and outpatient hospital services; emergency services; short-term mental health outpatient care, medical treatment, and referral for alcohol or drug abuse; diagnostic laboratory and diagnostic therapeutic radiology; home health services; and preventive health services. However, basic health care services do not include vision care services.
The primary difference between a preferred provider organization (PPO) and a point-of-service (POS) plan is that
A POS PLAN UTILIZES A GATEKEEPER, WHILE A PPO DOES NOT The main difference between a preferred provider organization and a point-of-service organization is that the POS organization uses a primary care physician (Gatekeeper) to provide greater cost control. Both types of plans allow the individual to go outside the system, though the individual then pays a higher portion of the costs.
The primary difference between a preferred provider organization (PPO) and a point-of-service (POS) plan is that
A POS PLAN UTILIZES A GATEKEEPER, WHILE A PPO DOES NOT The main difference between a preferred provider organization and a point-of-service organization is that the POS organization uses a primary care physician (gatekeeper) to provide greater cost control. Both types of plans allow the individual to go outside the system, though the individual then pays a higher portion of the costs.
Which of the following statements about preferred provider organizations (PPOs) is NOT true?
A PPO IS TYPICALLY A CLOSED PANEL OR A NETWORK WITH A PRIMARY CARE PHYSICIAN PPOs are designed as open panels or networks that offer care to insureds or entities through both in-network and out-of-network providers. Deductibles and coinsurance are higher for out-of-network care, as those providers and their fees are not part of a negotiated arrangement.
Which of the following statements pertaining to health maintenance organizations (HMOs) is CORRECT?
AN HMO OFFERS COMPREHENSIVE SERVICES ON A PREPAID BASIS TO ITS SUBSCRIBING MEMBERS An insurance company may sponsor an HMO or assist an HMO by providing contractual services. Many HMOs are independent. HMO members pay fixed periodic fees whether or not they use the HMO services; they are not subsequently charged for medical services performed.
To control costs, medical insurance plans available from commercial insurers and fraternal organizations are likely to provide care through
AN OPEN-NETWORK PPO Many commercial insurers and fraternal contract with independent physician groups and hospitals, creating extensive, often loosely organized preferred provider organizations for their insureds. Insureds are given lists of approved providers in their areas. Insures hav the option to go outside the system. However, reimbursements are higher when they use approved providers who are contracted at reduced rates.
All of the following are alternatives to hospital care EXCEPT
ASSISTED LIVING CARE Facilities other than hospitals may provide more cost-effective treatment and care for patients. However, the care must be under the supervision of a doctor and based on a prescribed level of care. Assisted living is not considered a form of medical care but is designed to assist an individual in maintaining a level of independence in performing activities of daily living.
All of the following are examples of medical cost management EXCEPT
DENYING CLAIMS Medical cost management is an effective means of controlling costs. It is the process of controlling how policyholders use their policies. There are 5 general approaches insurers use for cost management: mandatory second opinion, recertification review, ambulatory surgery, case management, and utilization management. Denying claims outright is not a legal or ethical method of controlling costs.
All of the following home health care serves will be covered by group plans EXCEPT
EMERGENCY SURGER Group medical benefits contracts must cover home care services. Home care services are services provided in a patient's residence, not in a hospital or skilled nursing or rehabilitation facility. These services must be approved by a physician. They include the following: Nursing and physical therapy, occupational therapy, speech therapy, medical social work, nutritional consultation, services of a home health aide, and use of durable medical equipment and supplies.
