Basics of the U.S. Health Care System Chapter 9 Exam Questions with Correct Solutions|
Latest Update Graded A+
Gatekeeper Primary Care Provider (PCP), coordinates all secondary and tertiary care, is
responsible for case management of a member patient, if additional care is required referral
must be made for patient, preauthorization for services is required with this model.
Utilization Review Evaluated the appropriateness of the types of services provided
Prospective Utilization Review Before the service is performed, procedure is preauthorized
by MCO, primary care provider refers member for service or assessing service based on clinical
guidelines.
Concurrent Utilization Review Decisions are made during course of service such as length of
inpatient stay and additional surgery
Retrospective Utilization Review An evaluation of services once services have been
provided. May occur to assess treatment patterns of certain diseases. May include a financial
review to assure accuracy of billing.
Practice Profiling Examines specific provider patterns of practice, a type of retrospective
utilization review, also a type of employee performance review because focus is to determine
which provider fits in with organizational culture of MCO
Risk plans Pay a premium per member based on the member's county of residence,
members can use both in-network and out-of-network providers, covers all Medicare services,
vision and prescription care.
Medicare cost plans A type of HMO, has similar rules to Medicare Advantage plans. CMS
reimburses MCOs on a preset monthly basis per enrollee based on a forecasted budget.
Reimbursement is based on reasonable cost of providing services, allow members to pursue
care outside network, if this occurs services are covered under original Medicare.
, Medicare Advantage Allows PPOs as an option, allows enrollees to participate in private fee-
for-service (PFFS) plans of MA. Formally known as Medicare+Choice
Managed Long Term Services and Supports (MLTSS) A CMS Medicaid program for expanding
home and community-based services to ensure quality and increase efficiency.
Limited benefit plans As part of MLTSS may look like an HMO but only provide one or two
Medicaid benefits (mental health or dental services).
Primary care case managers Individual or groups of providers agree to act as an individual's
primary care provider and receive a small monthly payment for helping to coordinate referrals
and other medical services.
Carve outs Services Medicaid is not obligated to pay for under an MCO contract, occur
because MCO cannot provide the service or it is too expensive.
National Committee on Quality Assurance (NCQA) (1990) Established to maintain the quality
of care in health plans. Focus is to measure, analyze and improve healthcare programs.
Accredits MCOs through a voluntary review process using surveys completed by managed care
experts and physicians. Evaluate access, service and quality of MCOs providers, primary
prevention activities and case management for the chronically ill.
Health Plan Employer Data and Information Set (HEDIS) Established by NCQA, used by over
90% of all health plans to measure service and quality of care, reported data is available to
MCOs and physicians.
Accreditation Association for Ambulatory Health Care (AAAHC) Reviews and accredits
managed care organizations, have Medicare Deemed Status from CMS, can survey Medicare
Advantage HMO and PPO plans
Latest Update Graded A+
Gatekeeper Primary Care Provider (PCP), coordinates all secondary and tertiary care, is
responsible for case management of a member patient, if additional care is required referral
must be made for patient, preauthorization for services is required with this model.
Utilization Review Evaluated the appropriateness of the types of services provided
Prospective Utilization Review Before the service is performed, procedure is preauthorized
by MCO, primary care provider refers member for service or assessing service based on clinical
guidelines.
Concurrent Utilization Review Decisions are made during course of service such as length of
inpatient stay and additional surgery
Retrospective Utilization Review An evaluation of services once services have been
provided. May occur to assess treatment patterns of certain diseases. May include a financial
review to assure accuracy of billing.
Practice Profiling Examines specific provider patterns of practice, a type of retrospective
utilization review, also a type of employee performance review because focus is to determine
which provider fits in with organizational culture of MCO
Risk plans Pay a premium per member based on the member's county of residence,
members can use both in-network and out-of-network providers, covers all Medicare services,
vision and prescription care.
Medicare cost plans A type of HMO, has similar rules to Medicare Advantage plans. CMS
reimburses MCOs on a preset monthly basis per enrollee based on a forecasted budget.
Reimbursement is based on reasonable cost of providing services, allow members to pursue
care outside network, if this occurs services are covered under original Medicare.
, Medicare Advantage Allows PPOs as an option, allows enrollees to participate in private fee-
for-service (PFFS) plans of MA. Formally known as Medicare+Choice
Managed Long Term Services and Supports (MLTSS) A CMS Medicaid program for expanding
home and community-based services to ensure quality and increase efficiency.
Limited benefit plans As part of MLTSS may look like an HMO but only provide one or two
Medicaid benefits (mental health or dental services).
Primary care case managers Individual or groups of providers agree to act as an individual's
primary care provider and receive a small monthly payment for helping to coordinate referrals
and other medical services.
Carve outs Services Medicaid is not obligated to pay for under an MCO contract, occur
because MCO cannot provide the service or it is too expensive.
National Committee on Quality Assurance (NCQA) (1990) Established to maintain the quality
of care in health plans. Focus is to measure, analyze and improve healthcare programs.
Accredits MCOs through a voluntary review process using surveys completed by managed care
experts and physicians. Evaluate access, service and quality of MCOs providers, primary
prevention activities and case management for the chronically ill.
Health Plan Employer Data and Information Set (HEDIS) Established by NCQA, used by over
90% of all health plans to measure service and quality of care, reported data is available to
MCOs and physicians.
Accreditation Association for Ambulatory Health Care (AAAHC) Reviews and accredits
managed care organizations, have Medicare Deemed Status from CMS, can survey Medicare
Advantage HMO and PPO plans
