OTP 510 Final Exam REVISED ACTUAL
Exam Questions and CORRECT Answers
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
managed care vs. HMO - CORRECT ANSWER - HMOs are organizations that serve
beneficiaries for a fixed fee and provide both financing and delivery of services
managed care - CORRECT ANSWER - a system that integrates the financing and delivery of
health services"
o Umbrella term used to describe organizational structures that link financing and health care
services
o Managed Care expands the role of the insurer using 3 principles
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 - o A panel of health care providers that are contracted with or employed by the
MCO
o Limiting the providers creates competition in areas of heavy MCO concentration
o Panels can be opened or closed
o Panels go through a credentialing process that reviews:
o Authorization of services = often primary care physicians serve as gatekeepers
•Managed Care Principle: #2: Payment mechanisms that reward efficiency - CORRECT
ANSWER - o Providers are reimbursed for their services through a variety of ways.
o Provider assumes either some or all of the financial risk
,o Discounted fee schedule =
o Bundle Payment System =
o Capitation =
•Managed Care Principle: #3: Enhanced quality control procedures - CORRECT ANSWER -
o MCOs perform utilization review, clinical pathways, benchmarking, and case management
functions
o Case managers = 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" (p.114).
o Therapy benefit managers = intermediary between the patient/therapist and insurer/MCO.
Evaluate the appropriateness of therapy. Employed by companies that contract with MCOs.
managed care products - CORRECT ANSWER - -aggregation
-managed indemnity
-preferred provider organization
-health maintenance organization
-point of service
-consumer-diected health plan
managed indemnity (managed care product) - CORRECT ANSWER - 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
aggregation (managed care product) - CORRECT ANSWER - the extent of integration
between financial and delivery components
More = bundle payments
Less = discounted fee for service
, preferred provider organization (managed care product) - CORRECT ANSWER - Contract
between providers and purchasers of health care/MCOs
Plans use pre approval, utilization review, and discounted reimbursement
Providers have an increased pool of patients, low financial investment, and more autonomy
Beneficiaries have a choice of providers within the panel
PPO is the primary employee-based insurance utilized (Kaiser, 2010), approx 69%
health maintenance organization (managed care product) - CORRECT ANSWER - Contract
between providers and purchasers of health care/MCOs
Plans use pre approval, utilization review, and discounted reimbursement
Providers have an increased pool of patients, low financial investment, and more autonomy
Beneficiaries have a choice of providers within the panel
PPO is the primary employee-based insurance utilized (Kaiser, 2010), approx 69%
point of service (managed care product) - CORRECT ANSWER - Hybrid plan containing
both HMO and PPO forms of managed care
Beneficiaries chose 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 (managed care product) - CORRECT ANSWER - Often used
with PPO models
Allow individuals greater control over health care utilization and spending
To discourage overuse of services many require co-payments
Health Savings Accounts (HSAs) often used with high deductible health plans (HDHP) can also
discourage overuse of services
managed care product - CORRECT ANSWER - o High deductible Health plans (HDHP)
Exam Questions and CORRECT Answers
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
managed care vs. HMO - CORRECT ANSWER - HMOs are organizations that serve
beneficiaries for a fixed fee and provide both financing and delivery of services
managed care - CORRECT ANSWER - a system that integrates the financing and delivery of
health services"
o Umbrella term used to describe organizational structures that link financing and health care
services
o Managed Care expands the role of the insurer using 3 principles
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 - o A panel of health care providers that are contracted with or employed by the
MCO
o Limiting the providers creates competition in areas of heavy MCO concentration
o Panels can be opened or closed
o Panels go through a credentialing process that reviews:
o Authorization of services = often primary care physicians serve as gatekeepers
•Managed Care Principle: #2: Payment mechanisms that reward efficiency - CORRECT
ANSWER - o Providers are reimbursed for their services through a variety of ways.
o Provider assumes either some or all of the financial risk
,o Discounted fee schedule =
o Bundle Payment System =
o Capitation =
•Managed Care Principle: #3: Enhanced quality control procedures - CORRECT ANSWER -
o MCOs perform utilization review, clinical pathways, benchmarking, and case management
functions
o Case managers = 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" (p.114).
o Therapy benefit managers = intermediary between the patient/therapist and insurer/MCO.
Evaluate the appropriateness of therapy. Employed by companies that contract with MCOs.
managed care products - CORRECT ANSWER - -aggregation
-managed indemnity
-preferred provider organization
-health maintenance organization
-point of service
-consumer-diected health plan
managed indemnity (managed care product) - CORRECT ANSWER - 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
aggregation (managed care product) - CORRECT ANSWER - the extent of integration
between financial and delivery components
More = bundle payments
Less = discounted fee for service
, preferred provider organization (managed care product) - CORRECT ANSWER - Contract
between providers and purchasers of health care/MCOs
Plans use pre approval, utilization review, and discounted reimbursement
Providers have an increased pool of patients, low financial investment, and more autonomy
Beneficiaries have a choice of providers within the panel
PPO is the primary employee-based insurance utilized (Kaiser, 2010), approx 69%
health maintenance organization (managed care product) - CORRECT ANSWER - Contract
between providers and purchasers of health care/MCOs
Plans use pre approval, utilization review, and discounted reimbursement
Providers have an increased pool of patients, low financial investment, and more autonomy
Beneficiaries have a choice of providers within the panel
PPO is the primary employee-based insurance utilized (Kaiser, 2010), approx 69%
point of service (managed care product) - CORRECT ANSWER - Hybrid plan containing
both HMO and PPO forms of managed care
Beneficiaries chose 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 (managed care product) - CORRECT ANSWER - Often used
with PPO models
Allow individuals greater control over health care utilization and spending
To discourage overuse of services many require co-payments
Health Savings Accounts (HSAs) often used with high deductible health plans (HDHP) can also
discourage overuse of services
managed care product - CORRECT ANSWER - o High deductible Health plans (HDHP)
