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