CERTIFIED LATEST
SPECIALIST
ACCOUNTING AND
FINANCE (CSAF)
COURSE FROM
HFMA
Healthcare providers should develop different modeling tools depending
on ____________. - ANSWERS-The reimbursement method proposed
in the contract. However, in any proposed contract, the provider should
quantify the anticipated revenues as well as the cost of providing the
proposed services at the projected utilization levels.
Risk-Sharing Arrangements - ANSWERS-Risk-Sharing Arrangements
Managed care arrangements have required providers to assume more of
the economic risks that accompany healthcare delivery. With the
exception of fee-for-service contracts, which are becoming much less
prevalent, the provider receives a set reimbursement amount, regardless
of the services performed.
In a per diem contract, the hospital is at risk for shorter, more resource
intensive inpatient stays. Where case rates have been negotiated, the
hospital is at risk for higher acuity admissions that are more costly. In
both of these examples, physician practice patterns can significantly
impact the profitability of the institutional provider.
END OF
PAGE
1
, CERTIFIED LATEST
SPECIALIST
ACCOUNTING AND
FINANCE (CSAF)
COURSE FROM
HFMA
Because of this interrelationship, health plans are creating contracts that
provide incentives for the physicians and institutional providers to align
practice patterns to achieve high-quality, cost-effective care. The most
common technique is to create a risk-sharing arrangement—a risk pool
that is shared by the providers based on predetermined performance
goals.
Managed care arrangements generally result in providers: - ANSWERS-
Assuming greater financial risk for the level of services provided.
With the exception of fee-for-service arrangements, providers are at risk
for the level of services beyond that used to establish the reimbursement
rates.
Quality and Risk-Based Payment - ANSWERS-The most common type
of risk-sharing arrangement is a quality and risk-based payment. Quality
and risk-based payment plans develop medical benefit budgets for each
of the primary benefit categories. The health plan withholds a portion of
the provider payments in a risk pool fund and rewards providers for the
END OF
PAGE
2
, CERTIFIED LATEST
SPECIALIST
ACCOUNTING AND
FINANCE (CSAF)
COURSE FROM
HFMA
efficiency by returning the withheld amounts as well as a share in
budgetary surpluses, based on individual performance.
Quality indicators - ANSWERS-Quality indicators are also monitored to
ensure patient care standards are maintained. These arrangements treat
providers more equitably by allowing them to share in both utilization
risk and reward. It also holds providers accountable for overuse of
resources by transferring utilization risk, up to the risk pool amount, to
the provider.
Identifying Reimbursement at Risk - ANSWERS-When modeling
proposed managed care contracts, any reimbursement that is at risk must
be identified. The extent to which risk-based reimbursement will
ultimately be achieved is dependent on the performance of every other
provider participating in the plan and the extent to which the participant
incentives have been properly aligned.
END OF
PAGE
3
, CERTIFIED LATEST
SPECIALIST
ACCOUNTING AND
FINANCE (CSAF)
COURSE FROM
HFMA
Provider Excess Loss Insurance - ANSWERS-The greater the risk
assumed by the provider in accepting a managed care contract, the more
important it is to consider minimizing the exposure by transferring, or
reinsuring, the risk. Capitation contracts, in particular, leave the provider
at risk for adverse experience. There are different types of excess loss
insurance available to the provider that should be considered given the
risks assumed for a particular contract. The general categories are:
-Per-person
-Aggregate
-Carve-out
Per-Person Excess Loss Insurance - ANSWERS-Per-person excess loss
insurance, also known as specific excess loss insurance, is the most
common and familiar coverage available. Per-person excess loss
insurance reimburses the provider once costs for an individual patient
exceed a specified threshold or deductible. This coverage is designed to
protect the provider against large and unforeseen claims for the
population defined in the policy. These policies generally include
END OF
PAGE
4
SPECIALIST
ACCOUNTING AND
FINANCE (CSAF)
COURSE FROM
HFMA
Healthcare providers should develop different modeling tools depending
on ____________. - ANSWERS-The reimbursement method proposed
in the contract. However, in any proposed contract, the provider should
quantify the anticipated revenues as well as the cost of providing the
proposed services at the projected utilization levels.
Risk-Sharing Arrangements - ANSWERS-Risk-Sharing Arrangements
Managed care arrangements have required providers to assume more of
the economic risks that accompany healthcare delivery. With the
exception of fee-for-service contracts, which are becoming much less
prevalent, the provider receives a set reimbursement amount, regardless
of the services performed.
In a per diem contract, the hospital is at risk for shorter, more resource
intensive inpatient stays. Where case rates have been negotiated, the
hospital is at risk for higher acuity admissions that are more costly. In
both of these examples, physician practice patterns can significantly
impact the profitability of the institutional provider.
END OF
PAGE
1
, CERTIFIED LATEST
SPECIALIST
ACCOUNTING AND
FINANCE (CSAF)
COURSE FROM
HFMA
Because of this interrelationship, health plans are creating contracts that
provide incentives for the physicians and institutional providers to align
practice patterns to achieve high-quality, cost-effective care. The most
common technique is to create a risk-sharing arrangement—a risk pool
that is shared by the providers based on predetermined performance
goals.
Managed care arrangements generally result in providers: - ANSWERS-
Assuming greater financial risk for the level of services provided.
With the exception of fee-for-service arrangements, providers are at risk
for the level of services beyond that used to establish the reimbursement
rates.
Quality and Risk-Based Payment - ANSWERS-The most common type
of risk-sharing arrangement is a quality and risk-based payment. Quality
and risk-based payment plans develop medical benefit budgets for each
of the primary benefit categories. The health plan withholds a portion of
the provider payments in a risk pool fund and rewards providers for the
END OF
PAGE
2
, CERTIFIED LATEST
SPECIALIST
ACCOUNTING AND
FINANCE (CSAF)
COURSE FROM
HFMA
efficiency by returning the withheld amounts as well as a share in
budgetary surpluses, based on individual performance.
Quality indicators - ANSWERS-Quality indicators are also monitored to
ensure patient care standards are maintained. These arrangements treat
providers more equitably by allowing them to share in both utilization
risk and reward. It also holds providers accountable for overuse of
resources by transferring utilization risk, up to the risk pool amount, to
the provider.
Identifying Reimbursement at Risk - ANSWERS-When modeling
proposed managed care contracts, any reimbursement that is at risk must
be identified. The extent to which risk-based reimbursement will
ultimately be achieved is dependent on the performance of every other
provider participating in the plan and the extent to which the participant
incentives have been properly aligned.
END OF
PAGE
3
, CERTIFIED LATEST
SPECIALIST
ACCOUNTING AND
FINANCE (CSAF)
COURSE FROM
HFMA
Provider Excess Loss Insurance - ANSWERS-The greater the risk
assumed by the provider in accepting a managed care contract, the more
important it is to consider minimizing the exposure by transferring, or
reinsuring, the risk. Capitation contracts, in particular, leave the provider
at risk for adverse experience. There are different types of excess loss
insurance available to the provider that should be considered given the
risks assumed for a particular contract. The general categories are:
-Per-person
-Aggregate
-Carve-out
Per-Person Excess Loss Insurance - ANSWERS-Per-person excess loss
insurance, also known as specific excess loss insurance, is the most
common and familiar coverage available. Per-person excess loss
insurance reimburses the provider once costs for an individual patient
exceed a specified threshold or deductible. This coverage is designed to
protect the provider against large and unforeseen claims for the
population defined in the policy. These policies generally include
END OF
PAGE
4
