HCD MIDTERM QUESTIONS AND ANSWERS
What can be used for recruitment of employees and providers to rural areas of practice?
- answer -managed care organizations
When did mco's begin to expand? - answer -during wwii
Hmo act of 1973 - answer -required employers with more than 25 employees to offer
this type of plan if traditional plans were offered
When did the requirement to offer hmos expire - answer -1990's
Why was there such a decrease in the 90's/2000 in enrollment in hmos? - answer -
because of the unaffordability and falling out of favor with those eligible for the plan .
Functions of managed care - answer -administrative , underwriting, and delivery
Administrative functions of mco - answer -premiums based on contract negotiations
between employers and mco
Underwriting functions of mco - answer -organization takes the financial responsibility if
total cost of services provided exceeds revenue from fixed premiums
What does fixed premium per enrollee include - answer -all health care services
provided for in the contract
Delivery function of mco - answer -organization promises to provide a comprehensive
set of services by contracting arrangements with physicians, clinics, and hospitals
(network of providers)
How do mco's acquire enrollees ? - answer -through the use of market strategy
Are mco's required to become accredited? - answer -no! No! No! Voluntary
What are the 3 agencies that accredit hmos or ppos - answer -the joint commission,
national committee for quality assurance ncqa, and the utilization review for
accreditation commission urac
What accreditation standards do hmos follow - answer -ncqa
What accreditation standards do ppos follow - answer -urac
How does ncqa promote performance standards and quality assurance - answer -hedis
,What does mco quality assessment involve? - answer -structure, process, and
outcomes
The seven essential features of mcos - answer --cost containment , accountability for
quality of care, measurement of health outcomes ,and quality of care, health promotion
and disease management programs, management of resource consumption , consumer
education programs , and continuing quality improvement
Case management for monitoring and controlling cost of mco - answer -an experienced
health care professional with knowledge of available resources monitors the patients
care along with the case manager to create a cost effective and efficient care plan for
the patient
Utilization review for monitoring and controlling cost of mco - answer -assessing the
appropriateness of the services provided to the patients .
The utlization review process includes - answer -reviewing each patient's case to
determine the level of services appropriate , the setting the delivery of services will take
place , determine the most cost effective method ,and the need for followup/subsequent
care
What are the two types of utilization review - answer -prospective and retrospective
Prospective ur - answer -appropriateness of care is determined before the care is
delivered
Retrospective ur - answer -managing services after care is already delivers by
reviewing medical records
Practice profiling for monitoring and controlling cost of mco - answer -used to decide
which providers have the right fit with the plans managed care philosophy and goals
and is also used to give feedback to providers so they can modify their own behavior of
medical practice
Practice profiling with mco - answer -is also know as profile monitoring , and is the
development of provider -specific practice patterns and comparisons of individual
practice patterns to some norm
Mco provider payment mechanisms include - answer -capitation, salaries, and
discounted fee
Capitation - answer -is when the provider is paid a fixed monthly sum per enrollee,
often call per member per month payment pmpm
Salaries - answer -is when the provider is paid , including bonuses or withholdings ,
provider=employee of mco
, Discounted fee - answer -is when the provider is paid after the services have been
delivered to the patient . The provider can bill the mco for each service separately but is
paid according to the pre-negotiated discount schedule (fee schedule)
What are the types of managed care organizations - answer -hmo, ppo, epo, pos
What are the hmo types - answer -staff hmo, group hmo, network hmo, independent
practice association ipa
Hmo stands for - answer -health maintenance organization
Ppo stands for - answer -preferred provider organization
Epo stand for - answer -exclusive provider organization
Pos stands for - answer -point of service
How does mco control costs - answer -through eliminating insurance an payer
intermediaries , sharing risk with providers, extracting discounts from providers,
coordinating a patient services and monitoring care to determine appropriateness and
cost effectiveness
What are the strategies mco use to monitor care, determine appropriate care , and cost
effectiveness - answer -choice restrictions , case management, practice profiling, gate
keeping, and utilization review
Choice restrictions for monitoring and controlling cost of mco - answer -the physician is
an employee of the mco or has a contract with the mco and is on the mco panel which
can be closed , in network panel , or an open , out of network panel
Gate keeping for monitoring and controlling cost of mco - answer -when the pcp
coordinates all health care services with an emphasis on preventative care, routine
physical exams. The pcp refers the patient to a consultation with a specialist , overall
controlling the patients utilization of healthcare
What are the differing characteristics of managed care plans - answer -risk bearing ,
physician type, out of network coverage , relationship exclusivity
What 2 managed care plans have out of network coverage - answer -ppo and pos
What 2 managed care plans have exclusivity of relationship - answer -hmo staff and
hmo group
What 2 managed care plans have large groups of physician types - answer -hmo group
and hmo network
What can be used for recruitment of employees and providers to rural areas of practice?
- answer -managed care organizations
When did mco's begin to expand? - answer -during wwii
Hmo act of 1973 - answer -required employers with more than 25 employees to offer
this type of plan if traditional plans were offered
When did the requirement to offer hmos expire - answer -1990's
Why was there such a decrease in the 90's/2000 in enrollment in hmos? - answer -
because of the unaffordability and falling out of favor with those eligible for the plan .
Functions of managed care - answer -administrative , underwriting, and delivery
Administrative functions of mco - answer -premiums based on contract negotiations
between employers and mco
Underwriting functions of mco - answer -organization takes the financial responsibility if
total cost of services provided exceeds revenue from fixed premiums
What does fixed premium per enrollee include - answer -all health care services
provided for in the contract
Delivery function of mco - answer -organization promises to provide a comprehensive
set of services by contracting arrangements with physicians, clinics, and hospitals
(network of providers)
How do mco's acquire enrollees ? - answer -through the use of market strategy
Are mco's required to become accredited? - answer -no! No! No! Voluntary
What are the 3 agencies that accredit hmos or ppos - answer -the joint commission,
national committee for quality assurance ncqa, and the utilization review for
accreditation commission urac
What accreditation standards do hmos follow - answer -ncqa
What accreditation standards do ppos follow - answer -urac
How does ncqa promote performance standards and quality assurance - answer -hedis
,What does mco quality assessment involve? - answer -structure, process, and
outcomes
The seven essential features of mcos - answer --cost containment , accountability for
quality of care, measurement of health outcomes ,and quality of care, health promotion
and disease management programs, management of resource consumption , consumer
education programs , and continuing quality improvement
Case management for monitoring and controlling cost of mco - answer -an experienced
health care professional with knowledge of available resources monitors the patients
care along with the case manager to create a cost effective and efficient care plan for
the patient
Utilization review for monitoring and controlling cost of mco - answer -assessing the
appropriateness of the services provided to the patients .
The utlization review process includes - answer -reviewing each patient's case to
determine the level of services appropriate , the setting the delivery of services will take
place , determine the most cost effective method ,and the need for followup/subsequent
care
What are the two types of utilization review - answer -prospective and retrospective
Prospective ur - answer -appropriateness of care is determined before the care is
delivered
Retrospective ur - answer -managing services after care is already delivers by
reviewing medical records
Practice profiling for monitoring and controlling cost of mco - answer -used to decide
which providers have the right fit with the plans managed care philosophy and goals
and is also used to give feedback to providers so they can modify their own behavior of
medical practice
Practice profiling with mco - answer -is also know as profile monitoring , and is the
development of provider -specific practice patterns and comparisons of individual
practice patterns to some norm
Mco provider payment mechanisms include - answer -capitation, salaries, and
discounted fee
Capitation - answer -is when the provider is paid a fixed monthly sum per enrollee,
often call per member per month payment pmpm
Salaries - answer -is when the provider is paid , including bonuses or withholdings ,
provider=employee of mco
, Discounted fee - answer -is when the provider is paid after the services have been
delivered to the patient . The provider can bill the mco for each service separately but is
paid according to the pre-negotiated discount schedule (fee schedule)
What are the types of managed care organizations - answer -hmo, ppo, epo, pos
What are the hmo types - answer -staff hmo, group hmo, network hmo, independent
practice association ipa
Hmo stands for - answer -health maintenance organization
Ppo stands for - answer -preferred provider organization
Epo stand for - answer -exclusive provider organization
Pos stands for - answer -point of service
How does mco control costs - answer -through eliminating insurance an payer
intermediaries , sharing risk with providers, extracting discounts from providers,
coordinating a patient services and monitoring care to determine appropriateness and
cost effectiveness
What are the strategies mco use to monitor care, determine appropriate care , and cost
effectiveness - answer -choice restrictions , case management, practice profiling, gate
keeping, and utilization review
Choice restrictions for monitoring and controlling cost of mco - answer -the physician is
an employee of the mco or has a contract with the mco and is on the mco panel which
can be closed , in network panel , or an open , out of network panel
Gate keeping for monitoring and controlling cost of mco - answer -when the pcp
coordinates all health care services with an emphasis on preventative care, routine
physical exams. The pcp refers the patient to a consultation with a specialist , overall
controlling the patients utilization of healthcare
What are the differing characteristics of managed care plans - answer -risk bearing ,
physician type, out of network coverage , relationship exclusivity
What 2 managed care plans have out of network coverage - answer -ppo and pos
What 2 managed care plans have exclusivity of relationship - answer -hmo staff and
hmo group
What 2 managed care plans have large groups of physician types - answer -hmo group
and hmo network
