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