Health Insurance Exam- Unit 17 Other Health Plans
parties to the provider contract
-A PPO is a risk-bearing entity separate from the providers of health care services -The relationship between the PPO and its providers is contractual. -However, a PPO can be organized by a number of different types of organizations, including: ■ insurance companies; ■ Blue Cross/Blue Shield; ■ a hospital or a group of hospitals; ■ a group of physicians; ■ an HMO; ■ a large employer or group of employers; and ■ a trade union.
preventive care
-A major difference between HMOs and the traditional health care system is the emphasis on preventive care -Traditional health insurance pays for the medical treatment of existing illnesses or other conditions. -HMOs seek to reduce the need for medical treatment by detecting conditions early before they require more extensive treatment -Routine physicals, well-child care, immunizations, and diagnostic screening are all included in the HMO subscription fee.
gatekeeper concept (primary care physician)
-Another way HMOs control over-utilization of their services by subscribers is with the gatekeeper concept -When subscribers join an HMO, they must choose a doctor with a general medical practice as their primary care physician (PCP) and they must always see them first (except in emergencies) when seeking medical care from the HMO. -Subscribers cannot see specialists without a referral from a primary care physician.
alternatives to hospital care
-Facilities other than a hospital may provide a more appropriate— and cost-effective—level of care for some patients. *Skilled nursing facilities -provide round-the-clock care for patients who need inpatient supervision by a registered nurse, but who do not require the acute level of care provided by a hospital. *Intermediate nursing facilities -provide intermittent nursing care for patients who do not need 24-hour supervision. *Rehabilitative facilities -provide a limited amount of medical care along with the personal care necessary for patients to recover from major surgeries or serious injuries or illnesses. *Home health care -provided by agencies that employ a staff of nurses that make visits to a patient's home on a regular basis. -It is used when patients need some sort of ongoing medical care but do not need supervision. *other facilities can be less expensive than hospital care
limited choice of provider
-HMO subscribers must choose a provider/physician under contract with the HMO -If a new subscriber's current physician is not under contract with the HMO, they must choose a doctor from the HMO -In some cases, the individual's current doctor may be able to join the HMO.
prepayment for health care services
-HMOs are considered prepaid plans because the consumer (subscriber) pays a subscription fee in advance for health care services they may need in the future -In addition to a co-payment paid by the subscriber, the HMO pays a capitation fee to a health care provider -The capitation fee is a fixed monthly fee paid to the healthcare provider based on the number of HMO members, not per HMO subscriber visit or service.
open panel vs. closed panel (HMO vs. PPO)
-HMOs are typically closed-panel, or closed network, entities subscribers must seek care only from providers/physicians that belong to the HMO (except in out-of-network emergencies). -PPOs are typically open panel, or open network, entities and subscribers are not strictly limited to the plans providers. The reimbursement percentage on care received from out-of-network providers however is usually considerably lower (50% to 60% than that for in-network providers (80% to 90%)
co-payments (co-pays)
-HMOs introduced the concept of co-payments, or co-pays instead of deductibles or coinsurance -A co-pay is a relatively small, flat dollar amount that subscribers must pay for each doctor visit.
other services
-HMOs must also provide for other basic office-based care provided by physicians and other medical professionals such as diagnostic services, treatment services, short-term physical therapy and rehabilitation services, laboratory and x-ray services, and outpatient surgery. -HMOs may include certain supplemental health care services or provide them for an additional fee, such as: ■ prescription drugs, ■ vision care, ■ dental care, ■ home health care, ■ nursing services, ■ long-term care, and ■ substance abuse treatment.
emergency care
-HMOs must provide emergency care, including ambulance service, available 24-hours a day, and 365 days a year, within its designated service area -In addition, HMOs must reimburse subscribers for emergency care obtained outside of the HMO's designated service area from non-HMO providers.
limited service area
-HMOs operate within a specific geographic area or designated service area such as a certain county or within the surrounding area -Individual must live within the designated service area to subscribe to the HMO
general characteristics of HMO's
-Health maintenance organizations (HMOs) are managed care entities -They departed from the traditional health care delivery and payment system in several key respects. -HMOs provide both the health care service and the health care financing, while traditional health care insurance companies provide only the financing.
combined health care deliver & financing
-In the traditional system, the insurance company acts as financing entity, collecting premiums and either paying the bulk of the patients' medical bills or reimbursing their medical expenses -Insurers assumed a certain amount of risk by hoping premiums would be sufficient to pay for provided medical care. -Health maintenance organizations changed this procedure by combining both the provision and the financing of health care into one entity -HMOs are made up of an array of physicians, hospitals, and other medical providers who offer a full range of health care services -Individuals pay for services directly to the HMO, and it agrees to provide needed medical care -The HMO is a financing entity and assumes that the cost of medical care will not exceed the subscription fees.
hospital services
-Inpatient hospital and physician care must be provided for a period per calendar year for treatment of illness or injury Hospital services must include the following: ■ room and board, ■ maternity care, ■ general nursing care, ■ use of operating room and facilities, ■ use of intensive care unit, ■ x-rays, laboratory, and other diagnostic tests, ■ drugs, medications, and anesthesia, and ■ physical, radiation, and inhalation therapy.
cost saving measures (preventative care)
-One of the cost saving measures insurers implemented was to encourage preventive care -It is much cheaper to prevent illnesses or to find and treat them in their early stages -Insurers began providing coverage for regular physical exams, health screenings, and smoking cessation programs, and wellness programs to provide access to experts in nutrition and exercise.
indemnity (traditional insurance) plans
-Traditional indemnity plans are still offered by commercial insurers. They are characterized by the following: ■ provision of care on a fee-for-service basis; ■ billing and submission of claim forms; ■ deductibles and coinsurance requirements; ■ complete freedom on choice of provider; and ■ ability to access to specialists without a referral. -Some traditional insurance plans employ certain cost containment methods such as preauthorization, second surgical opinion, or utilization management. -Some do not.
health care cost containment (manage care)
-Traditionally, controlling health care costs was not thought to be an area of responsibility for insurers. -But as health care costs began to rise dramatically, insurers responded by implementing a number of measures to make the delivery of health care more efficient and cost-effective -These measures came to be known as managed care *** *managed care -preventive care -reducing hospital care costs *cost saving measures: -well checks, annual visits, routine visits, wellness programs, smoking cessation programs, weight loss programs
point-of-service plans
-a type of HMO that allows subscribers to obtain care from providers who do not belong to the HMO as well as those who do -The name of the plan highlights the fact that subscribers can choose their point of service. -If subscribers choose to access care within the HMO, they choose a primary care physician who acts as a gatekeeper to the HMO's network of providers. -For this reason, POS plans are sometimes referred to as gatekeeper PPOs -In-network care is covered by the subscriber's prepaid fee -No billing is done and no claim forms need to be completed. *If subscribers choose to access care outside of the HMO, the plan operates like a PPO or traditional insurance plan: -there is no primary care physician who acts as a gatekeeper; -providers bill the individual a fee for services rendered, and the individual must submit a claim form to the HMO for reimbursement; and -subscribers are not reimbursed for 100% of their expenses but rather for only a percentage such as 60% or 80%, like a coinsurance requirement. -Because subscribers are not limited to selecting only providers which belong to the HMO, POS plans are sometimes called open-ended HMOs. *** -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 *sometimes referred to as gatekeeper PPO's or open-ended
retrospective review
-done after treatment is complete -The outcome is evaluated to see if treatment was effective and if anything could be changed to produce a better or most cost-effective outcome in the future.
reducing hospital care costs
-insurers also implemented measures designed to reduce the amount spent on inpatient hospitalization, which is the most costly type of medical care *outpatient benefits -Many procedures can be performed safely and effectively without the patient staying in the hospital overnight -Insurers began encouraging use of a hospital's outpatient facilities by providing relatively higher levels of reimbursement for treatment received on an outpatient rather than an in-patient basis -In addition, insurers began approving payment for treatment received in ambulatory care centers other than hospital outpatient departments such as surgicenters and urgent care centers *second surgical opinion -Doctors do not always agree on whether surgery is needed to treat a particular condition. -Second surgical opinion allows or requires consultation with a doctor other than their attending physician to see if an alternative method of treatment would be desirable. *preauthorization -If treatment requiring hospitalization is recommended, precertification is required prior to obtaining the treatment. *limits on length of stay -In consultation with medical experts, insurers determined the appropriate number of days for various types of treatment. They limited payment to a certain number of days for a given procedure, assuming no complications.
Preferred Provider Organization (PPO)
-managed care -fee for service -pre-negotiated rates -insured pays less in network of PPO providers *fee for service rather than prepaid like HMOs
Health Maintence Organization (HMO)
-managed care -prepaid services -co-pays -gatekeeper (primary care physician) -limited choice of providers -limited service area
prospective review
-occurs before an expensive test or treatment recommended by a physician is actually provided, requires a second opinion, or both -Information on the case is reviewed to determine necessity and cost-effectiveness -this review process is referred to as precertification or preauthorization.
utilization management
-places oversight on the provision of medical care to make sure it is appropriate and effective -This oversight can occur at any or all of the following points in the process. *** -prospective review -concurrent review -retrospective review *review to make sure medical care is appropriate & effective
What is an HMO known for?
-preventative care -gatekeeper concept, co-payments, & limited choice of provider are characteristics
categories of care/services of HMOs
-preventive care -emerency care--in or out of the service area -hospital services -office based care & outpatient services *major emphasis on preventative care *goal: detect conditions early before they require more treatment
concurrent review
-takes place while treatment is being provided The insured's hospital stay is monitored to assure that everything is proceeding according to schedule and that the insured will be released from the hospital as planned.
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 A. point-of-service plan B. traditional insurance plan C. preferred provider plan D. cost containment plan
A
All of the following are features of HMO's EXCEPT A. medical services are provided first, and then they are billed and paid for B. medical services are prepaid before treatment C. HMO's do not have deductibles or coinsurance, but instead co-payments D. HMO subscribers are not free to choose any provider that they wish
A
David has a PPO that does not limit him to use only providers that have contracts with the PPO. David's PPO is A. open panel B. closed panel C. choice panel D. guarded panel
A
All of the following are characteristics of a PPO EXCEPT A. PPO's operate on a fee-for-service B. PPO's operate on a prepaid basis C. PPO's are typically open panel entities D. the relationship between a PPO and its providers is contractual
B
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 A. open panel B. closed panel C. choice panel D. guarded panel
B
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 A. limits on lengths of stay B. preauthorization C. referral service D. outpatient benefits
B
PPO subscribers are not strictly limited to using providers that have contracts with the PPO. PPO's are A. closed-panel entities B. open-panel entities C. closed network entities D. free to choose entities
B
Which of the following alternatives to hospital care provides intermittent nursing care for patients who do not need 24 hour supervision? A. Skilled nursing facility B. Intermediate nursing facility C. Rehabilitative facility D. Home health care
B
All of the following are examples of managed care plans EXCEPT A. health maintenance organizations B. preferred provider organizations C. indemnity arrangements D. point-of-service plans
C
The main difference between traditional health insurance arrangements and HMOs is that A. traditional health insurance companies provide both the health care service and the health care financing, but HMOs provide only the health care financing B. traditional health care insurance companies provide both the health care service and the health care financing, but HMOs provide only the health care service C. HMOs provide both the health care service and the health care financing, but traditional health care insurance companies provide only the financing D. HMOs provide both the health care service and the health care financing, but traditional health care insurance companies provide only the service
C
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? A. Preauthorization B. Alternatives to hospital care C. Second surgical opinion D. Utilization management
C
Which utilization management review is done after the treatment is complete? A. Prospective review B. Concurrent review C. Retrospective review D. Complete review
C
all of the following are alternatives to hospital care EXCEPT A. skilled nursing facilities B. home health care C. utilization management D. rehabilitative facilities
C
All of the following are points in the process of utilization management EXCEPT A. prospective review B. concurrent review C. retrospective review D. alternative review
D
All of the following statements about an HMO are correct EXCEPT A. HMO's control overutilization of their services by subscribers with the gatekeeper concept B. HMO subscribers are not free to choose any subscriber that they wish C. HMO's are managed care entities D. HMO's operate on a fee for service plan
D
