Assignment 5.1
Explain the meaning of a stop loss provision that might appear in a managed care contract.
The patient service exceed a certain cost then the physician may ask the patient to pay
Name four types of health maintenance organization (HMO) models
A. Prepaid group practice model B. Staff model C. Network HMO D. Direct contract model
If a physician or hospital in a managed care plan is paid a fixed, per capita amount for each patient enrolled regardless of the type and number of services rendered, this is a payment system known as
Capitation
Medical services that are not included in a Managed Care contract capitalization rate but that may be contracted for separately are referred to as
Carve out
A type of payment model in which the patient pays a monthly annual fee to the physician is known as
Concierge medicine
A value-based reimbursement model in which providers receive performance-based incentives to share the access cost of healthcare delivery is called
Shared-risk
A specific dollar amount the patient must pay annually before an insurance plan begins covery Healthcare cost is called
Deductible
A type of managed care plan regulated under Insurance statues that combine featured of hmos and ppos and requires that employers agree not to contract with other plans is known as
EPO Exclusive provider organization
An insurance plan requires the insured to pay a fixed monthly premium. The insurance that will pay the health care organization for service is rendered is referred to as
FFE fee of service
A private health insurance are government-sponsored programs
False
All managed care plans are alike
False
Consumer-driven Health Plan are referred to as low deductible plan
False
Obtaining pre-approval for services always ensure payment of a claim by Insurance Company
False
When a healthcare organization agrees to accept a single negotiated fee to deliver all Medical Services related a patient's hip replacement surgery it is referred to as pay-for-performance
False
In a managed care setting, a primary care physician who controls patient access to specialist and diagnostic testing services is known as a/an
Gatekeeper
What type of medical insurance provides coverage of health services for a prepaid fixed annual fee and requires enrollees to seek services through a panel of providers contracted with the insurance company
HMO health maintenance organization
A group of techniques used by insurance companies to reduce the cost of providing health care while improving access to care and the quality of care is referred to as
Managed Care
A non for profit organization that has built a set off standards to which health plans attest that they have met key elements requires by state and federal laws allowing them to participate in managed care programs is called
NCQA national committee for quality assurance
Plan specified facilities listed in a managed care plan contracts where patients are required to have laboratory radiologic test performed are called
Network facilities
A health benefit program in which enrollees may choose any physician or hospital for services but obtain a higher level of benefits if preferred providers are used is known as a/an
PPO preferred providers organization
HMO and preferred providers organizations (ppo) consisting of a network of physicians and hospitals that provide an insurance company or employer with discounts on their services are referred to collectively as a/an
Point of service
A provider sponsored organization is a managed care plan that can be owned and operated by a hospital rather than an insurance company
True
Blue Cross plans provide Health Care coverage for Hospital expenses
True
The quality improvement system for managed care provides oversight and ensures accountability for managed care programs
True
Value-based reimbursement program reward Healthcare Providers with it said to payment for the quality of care they provide
True
Which of the following is term used in utilization review when the sickness high-cost patient are transferred to other Physicians
Turfing
To control health care costs, the process of reviewing and establishing medical necessity for services and providers use of medical care resources is termed
Utilization review
When the primary care physician informs the patient & telephone referring physician that the patient is being referred to for an appointment is called
Verbal referral
When a certain percentage of the monthly capitation payment or percentage of the allowable charges to physician is set aside to operate a managed care plan it is known as an
Withhold