OTP 510 Final Exam REVISED Exam
Questions and CORRECT Answers
Private Insurance - CORRECT ANSWER - Third-party, the patient, and health care provider
Individual pays premiums to the insurance company who in turn pays the provider
Individual may also have a deductible to pay each year before insurance coverage kicks in
Insurance companies may also require individuals to pay part of some services (coinsurance or
copayment)
Managed Care - CORRECT ANSWER - A system that integrates the financing and delivery of
health services
Umbrella term used to describe organizational structures that link financing and health care
services
For years we were sheltered from the rising costs of health care
Americans used the system without restriction and awareness of cost
Providers did not feel constrained to contain costs or hold back services
Health Maintenance Organization (HMO) Act of 1973 - CORRECT ANSWER - Managed
care and prepayment systems
Growth of managed care expedited by employer concerns about costs and ERISA exemptions
that prevented states from regulating employer sponsored self insured plans
HMO - CORRECT ANSWER - Organizations that serve beneficiaries for a fixed fee and
provide both financing and delivery of services
Managed Care Principles - CORRECT ANSWER - expands the role of the insurer using:
1) limited access to the universe of providers
,2) payment mechanisms that reward efficiency
3) enhanced quality control procedures
Managed Care Principle: #1: Limited access to the universe of providers - CORRECT
ANSWER - A panel of health care providers that are contracted with or employed by the
MCO
Geographic locations
Limiting the providers creates competition in areas of heavy MCO concentration
Panels can be opened (allow any provider to join panel) or closed (allow only select number)
Panels go through a credentialing process that reviews: education, clinical experience, and
professional behaviors of the health care providers
Authorization of services = PCP serves as a gatekeeper (refer out to services as needed)
Managed Care Principle: #2: Payment Mechanisms That Reward Efficiency - CORRECT
ANSWER - Providers are reimbursed for their services through a variety of ways.
Discounted fee schedule = provider accepts contract at less than full charge of service in
exchange for a set of patients who subscribe to the plan (insurer holds most financial risk)
Bundle Payment System = One fee to provider for a set of services (per visit or per day)
Capitation = separates payment from treatment (provider most risk; may withhold needed
treatments to make profit)
*What can this imbalance of risk cause? OT services are being withheld because it is too costly
to provide the services*
Discounted fee schedule - CORRECT ANSWER - provider accepts contract at less than full
charge of service in exchange for a set of patients who subscribe to the plan (insurer holds most
financial risk)
Bundle Payment System - CORRECT ANSWER - One fee to provider for a set of services
(per visit or per day)
,Capitation - CORRECT ANSWER - separates payment from treatment (provider most risk;
may withhold needed treatments to make profit)
Managed Care Principle: #3: Enhanced quality control procedures - CORRECT ANSWER -
MCOs perform utilization review, clinical pathways (track plan of care), benchmarking, and case
management functions
case managers = coordinate all aspects of patient care
Therapy Benefits Manager
Case Manager - CORRECT ANSWER - coordinate all aspects of patient care
"A collaborative process of assessment, planning facilitation, care coordination, evaluation, and
advocacy for options and services to meet an individual's and family's comprehensive health
needs through communication and available resources to promote quality cost-effective
outcomes"
Therapy Benefits Manager - CORRECT ANSWER - between patient, therapist, and insurer
(review documentation, medical charts, decide how many more visits are necessary/will be paid
for)
Managed Care Products - CORRECT ANSWER - Aggregation
Indemnity
Preferred Provider Organizations (PPO)
Health Maintenance Organizations (HMO)
Point of Service (POS)
Consumer Directed Health Plans
Aggregation - CORRECT ANSWER - the extent of integration between financial and delivery
components
More = bundle payments
Less = discounted fee for service
, Indemnity - CORRECT ANSWER - security or protection against a loss or other financial
burden
Least aggregated form
Fee for service reimbursement with a pre authorization component and utilization review
Beneficiary must get preauthorization but have maximum choice of providers and fewer
restrictions on amount and type of services
Preferred Provider Organizations (PPO) - CORRECT ANSWER - Contract between providers
and purchasers of health care/MCOs
Plans use pre approval, utilization review, and discounted reimbursement
Beneficiaries have a choice of providers within the panel
The most common plan type, 47% of enrolled
Health Maintenance Organizations (HMO) - CORRECT ANSWER - Is highly aggregated
form of managed care
Utilize gatekeepers/physicians to pre-approve
Utilization review to control costs
Beneficiaries access with pre-approval only, from only those providers in panel
Provider payment varies
Point of Service (POS) - CORRECT ANSWER - Hybrid plan
Beneficiaries choose provider at time of service
Benefits paid at a higher percentage within primary care/HMO provider rather than others in
panel/PPO
Rules are based on which option patient chooses
Consumer Directed Health Plans - CORRECT ANSWER - Often used with PPO models
Allow individuals greater control over health care utilization and spending
To discourage overuse of services many require copayments
Questions and CORRECT Answers
Private Insurance - CORRECT ANSWER - Third-party, the patient, and health care provider
Individual pays premiums to the insurance company who in turn pays the provider
Individual may also have a deductible to pay each year before insurance coverage kicks in
Insurance companies may also require individuals to pay part of some services (coinsurance or
copayment)
Managed Care - CORRECT ANSWER - A system that integrates the financing and delivery of
health services
Umbrella term used to describe organizational structures that link financing and health care
services
For years we were sheltered from the rising costs of health care
Americans used the system without restriction and awareness of cost
Providers did not feel constrained to contain costs or hold back services
Health Maintenance Organization (HMO) Act of 1973 - CORRECT ANSWER - Managed
care and prepayment systems
Growth of managed care expedited by employer concerns about costs and ERISA exemptions
that prevented states from regulating employer sponsored self insured plans
HMO - CORRECT ANSWER - Organizations that serve beneficiaries for a fixed fee and
provide both financing and delivery of services
Managed Care Principles - CORRECT ANSWER - expands the role of the insurer using:
1) limited access to the universe of providers
,2) payment mechanisms that reward efficiency
3) enhanced quality control procedures
Managed Care Principle: #1: Limited access to the universe of providers - CORRECT
ANSWER - A panel of health care providers that are contracted with or employed by the
MCO
Geographic locations
Limiting the providers creates competition in areas of heavy MCO concentration
Panels can be opened (allow any provider to join panel) or closed (allow only select number)
Panels go through a credentialing process that reviews: education, clinical experience, and
professional behaviors of the health care providers
Authorization of services = PCP serves as a gatekeeper (refer out to services as needed)
Managed Care Principle: #2: Payment Mechanisms That Reward Efficiency - CORRECT
ANSWER - Providers are reimbursed for their services through a variety of ways.
Discounted fee schedule = provider accepts contract at less than full charge of service in
exchange for a set of patients who subscribe to the plan (insurer holds most financial risk)
Bundle Payment System = One fee to provider for a set of services (per visit or per day)
Capitation = separates payment from treatment (provider most risk; may withhold needed
treatments to make profit)
*What can this imbalance of risk cause? OT services are being withheld because it is too costly
to provide the services*
Discounted fee schedule - CORRECT ANSWER - provider accepts contract at less than full
charge of service in exchange for a set of patients who subscribe to the plan (insurer holds most
financial risk)
Bundle Payment System - CORRECT ANSWER - One fee to provider for a set of services
(per visit or per day)
,Capitation - CORRECT ANSWER - separates payment from treatment (provider most risk;
may withhold needed treatments to make profit)
Managed Care Principle: #3: Enhanced quality control procedures - CORRECT ANSWER -
MCOs perform utilization review, clinical pathways (track plan of care), benchmarking, and case
management functions
case managers = coordinate all aspects of patient care
Therapy Benefits Manager
Case Manager - CORRECT ANSWER - coordinate all aspects of patient care
"A collaborative process of assessment, planning facilitation, care coordination, evaluation, and
advocacy for options and services to meet an individual's and family's comprehensive health
needs through communication and available resources to promote quality cost-effective
outcomes"
Therapy Benefits Manager - CORRECT ANSWER - between patient, therapist, and insurer
(review documentation, medical charts, decide how many more visits are necessary/will be paid
for)
Managed Care Products - CORRECT ANSWER - Aggregation
Indemnity
Preferred Provider Organizations (PPO)
Health Maintenance Organizations (HMO)
Point of Service (POS)
Consumer Directed Health Plans
Aggregation - CORRECT ANSWER - the extent of integration between financial and delivery
components
More = bundle payments
Less = discounted fee for service
, Indemnity - CORRECT ANSWER - security or protection against a loss or other financial
burden
Least aggregated form
Fee for service reimbursement with a pre authorization component and utilization review
Beneficiary must get preauthorization but have maximum choice of providers and fewer
restrictions on amount and type of services
Preferred Provider Organizations (PPO) - CORRECT ANSWER - Contract between providers
and purchasers of health care/MCOs
Plans use pre approval, utilization review, and discounted reimbursement
Beneficiaries have a choice of providers within the panel
The most common plan type, 47% of enrolled
Health Maintenance Organizations (HMO) - CORRECT ANSWER - Is highly aggregated
form of managed care
Utilize gatekeepers/physicians to pre-approve
Utilization review to control costs
Beneficiaries access with pre-approval only, from only those providers in panel
Provider payment varies
Point of Service (POS) - CORRECT ANSWER - Hybrid plan
Beneficiaries choose provider at time of service
Benefits paid at a higher percentage within primary care/HMO provider rather than others in
panel/PPO
Rules are based on which option patient chooses
Consumer Directed Health Plans - CORRECT ANSWER - Often used with PPO models
Allow individuals greater control over health care utilization and spending
To discourage overuse of services many require copayments
