Bundled codes
Steps used to control costs of Capitation
managed care include: Payer and Provider to agree on reasonable payment
Inpatient admissions for the purpose of reimbursing hospitals for
each case in a given category w/a negotiated fixed fee, regardless
DRG is used to classify of the actual costs incurred
HMO
Conventional
PPO and POS
HDHP/SO plans - high-deductible health plans with a savings
Identify the various types of option; Private - Include higher patient out-of-pocket expenditures
private health plan coverage for treatments that can serve to reduce utilization/costs.
Health Maintenance Organizations (HMO)
Managed care organizations Preferred Provider Organizations (PPO)
(MCO) exist primarily in four Point of Service (POS) Organizations
forms: Exclusive Provider Organizations (EPO)
Medicare - Government; Beneficiaries enrolled in such plans, but,
participation in these
plans is voluntary.
Medicaid
Identify the various types of
Medicaid Managed Care - Medicaid beneficiaries are required to
government‐sponsored health
select and enroll in a managed care plan.
coverage:
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
Demographics
Chronic Conditions
Provider payment systems - Provider payment systems that are
designed to reward volume rather than quality, outcomes, and
prevention
Consumer Perceptions
Identify some key drivers of
Health Plan pressure
increasing healthcare costs
Physician Relationships
Supply Chain
Referrals
PCP
Patients must use an in-network provider for their services to be
Health Maintenance covered.
Organizations (HMO) Reimbursement - majority of services offered are reimbursed
through capitation payments (PMPM)
, Part A - provides inpatient/hospital, hospice, and skilled nursing
coverage
Part B - provides outpatient/medical coverage
Part C - an alternative way to receive your Medicare benefits
Medicare is composed of four (known as Medicare
parts: Advantage)
Part D - prescription drug coverage
The HMO Act of 1973 gave federally qualified HMOs the right to
mandate that employers offer their product to their employees
under certain conditions. Mandating an employer meant that
employers who had 25 or more employees and were for‐profit
HMO Act of 1973 companies were required to make a dual choice available to their
employees.
The real advent of employer-based insurance came through Blue
Which of the following statements Cross, which was started by hospital associations during the
regarding employer-based health Depression.
insurance in the United States is
true?
Would have to offer HMO plans along side traditional fee-for-
The Health Maintenance service medical plans.
Organization (HMO) Act of 1973
gave qualified HMOs the right to
"mandate" an employer under
certain conditions, meaning
employers:
Providers will face many new service demands and consumers will
Which of the following is an have virtually unfettered access to those services
anticipated change in the
relationships between consumers
and providers?
A transition toward new models of health care delivery with
What transition began as a result corresponding changes system financing and provider
of the March 2010 healthcare reimbursement.
reform legislation?
Which statement is false ABN began establishing new requirements for managed care
plans participating in the Medicare program.
concerning ABNs?
-ABNs are not required for services that are never covered by
Medicare.
-An ABN form notifies the patient before he or she receives the
service that it may not be
covered by Medicare and that he or she will need to pay out of
pocket.
Which Statement is TRUE
-Although ABNs can have significant financial implications for the
concerning ABNs?
physician, they also
serve an important fraud and abuse compliance function.
The pay for medical assistance for certain individuals and low-
What is the overall function of
income families
Medicaid?
, Total Medical Expenses divided by Total Premiums
Medical Cost Ratio (MCR) or
Medical Loss Ratio (MLR) is
defined as:
Ties to the healthcare delivery industry rather than the insurance
Provider service organizations industry
(PSOs) function like health
maintenance organizations
(HMOs) in all of the following
ways, EXCEPT:
-Risk pooling
Provider service organizations -Capitalization
(PSOs) function like health -Network management
maintenance organizations
(HMOs) in all of the following
ways:
-Administrative
Which of the following is a -Utilization review (UR)
service provided by a well- -Claims processing
managed third-party
administrator (TPA)?
The ranking or classifying of one or more of the provider delivery
What is tiering? system components
-Making advance payment to providers for all services needed to
care for a member
-Combining services provided and bundling the associated
Which option is a practice used to charges
control costs of managed care? -Agreement between the payer and provider on reasonable
payment for each service.
-The risk to the insurance company or health plan
Which option is a risk involved in -The risk to the hospital
per diem payments? -The risk when embracing per diem payments in complex case
Diagnosis-related group (DRG) A payment category
is:
How is the term carve-out used To refer to specific benefits or services
when discussing managed care?
What is the term Coordination of A term used to describe how payment is coordinated for patients
Benefits (COB)? who have coverage through two insurance policies
-Malpractice expense
Which three components are -Lowest market price for services used
used to determine the total RVU -Medicare discounts
value for a service?
Steps used to control costs of Capitation
managed care include: Payer and Provider to agree on reasonable payment
Inpatient admissions for the purpose of reimbursing hospitals for
each case in a given category w/a negotiated fixed fee, regardless
DRG is used to classify of the actual costs incurred
HMO
Conventional
PPO and POS
HDHP/SO plans - high-deductible health plans with a savings
Identify the various types of option; Private - Include higher patient out-of-pocket expenditures
private health plan coverage for treatments that can serve to reduce utilization/costs.
Health Maintenance Organizations (HMO)
Managed care organizations Preferred Provider Organizations (PPO)
(MCO) exist primarily in four Point of Service (POS) Organizations
forms: Exclusive Provider Organizations (EPO)
Medicare - Government; Beneficiaries enrolled in such plans, but,
participation in these
plans is voluntary.
Medicaid
Identify the various types of
Medicaid Managed Care - Medicaid beneficiaries are required to
government‐sponsored health
select and enroll in a managed care plan.
coverage:
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
Demographics
Chronic Conditions
Provider payment systems - Provider payment systems that are
designed to reward volume rather than quality, outcomes, and
prevention
Consumer Perceptions
Identify some key drivers of
Health Plan pressure
increasing healthcare costs
Physician Relationships
Supply Chain
Referrals
PCP
Patients must use an in-network provider for their services to be
Health Maintenance covered.
Organizations (HMO) Reimbursement - majority of services offered are reimbursed
through capitation payments (PMPM)
, Part A - provides inpatient/hospital, hospice, and skilled nursing
coverage
Part B - provides outpatient/medical coverage
Part C - an alternative way to receive your Medicare benefits
Medicare is composed of four (known as Medicare
parts: Advantage)
Part D - prescription drug coverage
The HMO Act of 1973 gave federally qualified HMOs the right to
mandate that employers offer their product to their employees
under certain conditions. Mandating an employer meant that
employers who had 25 or more employees and were for‐profit
HMO Act of 1973 companies were required to make a dual choice available to their
employees.
The real advent of employer-based insurance came through Blue
Which of the following statements Cross, which was started by hospital associations during the
regarding employer-based health Depression.
insurance in the United States is
true?
Would have to offer HMO plans along side traditional fee-for-
The Health Maintenance service medical plans.
Organization (HMO) Act of 1973
gave qualified HMOs the right to
"mandate" an employer under
certain conditions, meaning
employers:
Providers will face many new service demands and consumers will
Which of the following is an have virtually unfettered access to those services
anticipated change in the
relationships between consumers
and providers?
A transition toward new models of health care delivery with
What transition began as a result corresponding changes system financing and provider
of the March 2010 healthcare reimbursement.
reform legislation?
Which statement is false ABN began establishing new requirements for managed care
plans participating in the Medicare program.
concerning ABNs?
-ABNs are not required for services that are never covered by
Medicare.
-An ABN form notifies the patient before he or she receives the
service that it may not be
covered by Medicare and that he or she will need to pay out of
pocket.
Which Statement is TRUE
-Although ABNs can have significant financial implications for the
concerning ABNs?
physician, they also
serve an important fraud and abuse compliance function.
The pay for medical assistance for certain individuals and low-
What is the overall function of
income families
Medicaid?
, Total Medical Expenses divided by Total Premiums
Medical Cost Ratio (MCR) or
Medical Loss Ratio (MLR) is
defined as:
Ties to the healthcare delivery industry rather than the insurance
Provider service organizations industry
(PSOs) function like health
maintenance organizations
(HMOs) in all of the following
ways, EXCEPT:
-Risk pooling
Provider service organizations -Capitalization
(PSOs) function like health -Network management
maintenance organizations
(HMOs) in all of the following
ways:
-Administrative
Which of the following is a -Utilization review (UR)
service provided by a well- -Claims processing
managed third-party
administrator (TPA)?
The ranking or classifying of one or more of the provider delivery
What is tiering? system components
-Making advance payment to providers for all services needed to
care for a member
-Combining services provided and bundling the associated
Which option is a practice used to charges
control costs of managed care? -Agreement between the payer and provider on reasonable
payment for each service.
-The risk to the insurance company or health plan
Which option is a risk involved in -The risk to the hospital
per diem payments? -The risk when embracing per diem payments in complex case
Diagnosis-related group (DRG) A payment category
is:
How is the term carve-out used To refer to specific benefits or services
when discussing managed care?
What is the term Coordination of A term used to describe how payment is coordinated for patients
Benefits (COB)? who have coverage through two insurance policies
-Malpractice expense
Which three components are -Lowest market price for services used
used to determine the total RVU -Medicare discounts
value for a service?
