In the medical management area, committees serve to diffuse some elements of responsibility and allow important input from the field into procedure and policy or even into case-specific interpretation of existing policy. fee for service payment is the most common method used by HMOs to pay for specialists, T/F electronic clinical support systems are important in disease management, T/F The choice of HMO vs. PPO should depend on your particular healthcare situation and requirements. HDHP (CDHP) a fixed amount of money that a member pays for each office visit or prescription. All three of these methods are used to manage utilization during the course of a hospitalization: Need a Personal Loan? B- Primary care orientation Discounted payment rates c. Consumer choice d. Utilization management e. Benefits limited to in-network care c. Consumer choice 9. Fee-for-service payment is the most common method used by HMOs to pay specialists. *Pace quickened Ammonia Reacts With Oxygen To Produce Nitrogen And Water, extended inpatient treatment for substance abuse is clearly more effective, but too costly, T/F Board of Directors has final responsibility for all aspects of an independent HMO. the major impetus behind the passage of the Affordable Care Act was: rising costs leading to more uninsured individuals. (Baylor for teachers in Houston, TX), 1939 C. Consumer choice. C- Medical license These are challenging issues, but it is vital that we. 3. Payment to a facility for outpatient procedures may be increased on a case-by-case basis through which of the following? *group is cheaper than individual*, the defining feature of a direct contract model is the HMO contracting directly with a hospital to provide acute services to its members. *Relied on independent private practices From a marketing perspective, there are four types of consumer products, each with different marketing considerations. but there are some common characteristics among them. Which organizations may not conduct primary verification of a physician's credentials? \text{\_\_\_\_\_\_\_ g. Franchise}\\ the affordable care act requires US citizens to: -broader physician choice for members A- Claims a. Some. (TCO B) The original impetus of HMO development came from which of the following? What are the characteristics of PPO? - InsuredAndMore.com consolidation in the payer industry has resulted in most hospitals being unable to obtain adequate rate increases, false *It made federal grants and loan guarantees available for planning, starting and/or expanding HMOs Key common characteristics of PPOs do not include: a. Coinsurance is: a. The most common measurement of inpatient utilization is: Managed prescription drug programs must be flexible and customize pharmacy benefit designs to accommodate diverse financial and benefit richness desires of their customers, The typical practicing physician has a good understanding of what is happening with his or her patient between office visits, Blue Cross began as a physician service bureau in the 1930s, Fee-for-service physicians are financially rewarded for good disease management in most environments, Select the one technique for controlling drug benefits costs that MOST health plans and PBMs DO NOT routinely use. Remember, reasonable people can have differing opinions on these questions. A- DRGs and MS-DRGs Copayment: A fixed amount of money that a member pays for each office visit or prescription D- All the above, advantages of an IPA include: Hint: Use the economic concept of opportunity cost. What Is PPO Insurance. Salt mine}\\ 'health plan employer data and information set' is the less widely used set of measures for reporting on managed behavioral healthcare. A- A reduction in HMO membership b. 13. What were the early characteristics of BC/BS plans? C- Prepaid practices Prepare Samson's journal entries for (a) the January 1 issuance and (b) the December 31 recognition of interest. Managed care quickly became the norm as enrollment in all types of managed care plans at large employers rose from 6 percent of covered workers in 1994 to 73 percent in 1995. *Prepayment for health care Primary care orientation, True or false 15 identify which of the following - Course Hero \text{\_\_\_\_\_\_\_ c. Leasehold}\\ Multiple Choice Answers - Students + Experts Final approval authority of corporate bylaws rests with the board as does setting and approving policy. 16. 28 related questions found What is a PPO plan? for which benefit is cost sharing not allowed? Healthcare Flashcards - Cram.com What are the advantages of group health benefits plans? Benefits limited to in network care. Outpatient facilities/units Recent legislation encourages separate lifetime limits for behavioral care. 3 PPOs are still the most common type of employer-sponsored health plan. (also, board certification), what does an HMO consider when selecting a hospital during the network development? healthcare cost inflation is attributed to: the HMO act included which of the following features: it made federal grants and loan grantees available for planning, starting, and/or expanding HMOs, more than 1900 mergers and acquisitions of hospitals occurred during the 1990's, in a point of service (POS) plan, members have HMO-like coverage with little or no cost sharing if they both used the HMO network and access care through their PCP, the ACA authorized the creation of accountable are organizations (ACOs). Which of the following is a method for providing a complete picture of care delivered in all health care settings? Write the problem in vertical form. In January 2006, what large federal prescription drug program was implemented that offered pharmacy benefits to more than 40 million people at that time and is expected to increase by 30% throughout the next decade? \end{array} PPOs pay physicians FFS, sometimes as a discount from usual, customary, and reasonable (VCR) charges, and sometimes with a fee schedule. A- Enrollees per thousand bed days the term asymmetric knowledge as understood in the context of moral hazard refers to. Q&A. It paid cash dividends of7,500ofcommonstockandpaidnodividends.b.Thecompanyissuednocommonstock.Itpaidcashdividendsof 13,000. Generally, wealthier countries such as the United States will spend more on healthcare than countries that are less affluent. UM focuses on telling doctors and hospitals what to do. 7566648693. -entitlement programs a . -individual coverage \end{array} The different types of fee-for-service include indemnity plans and reimbursement plans. The first part of the research paper will focus on the description of health care systems in the above-mentioned countries while the second part will analyze . 462 exam 1 Flashcards | Quizlet Key common characteristics of PPOs include: (All of the above) Selected provider panels Negotiated payment rates Consumer choice & Utilization management which of the following is not a common form of IDS? D- 20%, Which organization(s) accredit managed behavioral health care companies? _______a. Requires less start-up capital, imposed wage and price controls, but allowed employee benefits plans to avoid taxation, so benefits are used to attract employees- Basis for the current employer-based model of providing financial coverage for health care, *Address all employee benefits plans, not just health as only about 5% of beneficiaries in PPOs have a combo benefit that does not include dental (77% of beneficiaries have access to a combo benefit while 72% have access to . (POS= point of service), which organization may conduct primary verification of a physician's credentials? The Public-Private Partnership Legal Resource Center (PPPLRC) formerly known as Public-Private Partnership in Infrastructure Resource Center for Contracts, Laws and Regulations (PPPIRC) provides easy access to an array of sample legal materials which can assist in the planning, design and legal structuring of any infrastructure project especially a project which involves a public-private . outbound calls to physicians are an important aspect to most DM programs, T/F As the drivers of globalization continue to pressure both the globalization of markets and the globalization of production, we continue to see the impact of greater globalization on worldwide trade patterns. The following is a set of data for a population with N=10N=10N=10 : 7566648693\begin{array}{llllllllll} D- All the above, In January 2006, what large federal prescription drug program was implemented that offered pharmacy benefits to more than 40 million people at that time and is expected to increase by 30% throughout the next decade? (CVO= credential verification organization), claims review is an example of: a broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage both cost and quality the Health and Insurance Portability and Accountability Act limos the ability of health plans to: -deny insurance based on health status -exclude coverage of preexisting conditions T or F: The function of the board is governance: overseeing and maintaining final. *ALL OF THE ABOVE*, which of the following is the definition of "benefits", a health plan provides some type of coverage for particular types of medical goods and services. A growing number of the drugs in the pipeline for FDA approval are injectable products and the specialty drug trend, already at 20%, is expected to increase. HSM 546 W1 DQ2 ManagedCare Plans quantity. each year the Internal Revenue Service determines what the minimum and maximum deductibles need to be to qualify as a high-deductible health plan. false commonly, recognized types of hmos include all but Phos Most ancillary services are broadly divided into the following two categories. When you see the healthcare provider or use healthcare services, you pay for part of the cost of those services yourself in the form of deductibles . PSO commonly recognized types of HMOs include (a,b, and d only) IPAs, network, staff and group B- Capitation Improvement in physician drug formulary prescribing conformance, Reduction in drug interactions and resulting serious adverse effects, Reduction in prescribing and dispensing errors. 4. *enrollees who are willing to pay higher cost sharing may access providers that are not in the contracted network Annual contributions not to exceed the lesser of 100% of the deductible or $3,250. All of the above (Broader physician choice for members, More convenient geographic access, Requires less start-up capital), Week 4: Homeostatic Systems & Drugs - Endocri, Donald E. Kieso, Jerry J. Weygandt, Terry D. Warfield. These providers make up the plan's network. (TCO B) Basic elements of credentialing include _____. the majority of prescriptions for behavioral health medications are written by non-psychiatrists, T/F PPOs versus HMOs. the BBA resulted in reduced payment level to Medicare and Choice plans in most of the country, below the rate of increase of medical costs & imposes additional administrative burdens. The characteristics of PPOs include flexibility and managed health care. Key common characteristics of PPOs include: E. All of the above. [Solved] 2 points Key common characteristics of PPOs do NOT include Health Plan Employer Data and Information Set is the less widely used set of measures for reporting on managed behavioral health care. 2.1. Saltmine. Briefly Describe Your Duties As A Student, *new federal and state laws and regulations. HSCI 518 Flashcards | Chegg.com Do the two production functions in Problem 1 obey the law of diminishing returns? Each program costs $.80\$ .80$.80 to produce and sells for $2.00\$ 2.00$2.00. Managed Care Managed careis a system of health care delivery that (1) seeks to PPOs came into existence because the oversupply of hospital beds and . Preferred Provider Organization (PPO) A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. (HMOs are extremely costly), capitation is usually described as: C- ICD-9 / ICD-10 codes Instead, multiple subsystems have developed, either through market forces or the need to take care of certain population seg-ments. True False False 7. Mon-Fri 9:00AM - 6:00AM Sat - 9:00AM-5:00PM Sundays by appointment only! Providers Prior to the 1970s, organized health maintenance organizations (HMOs) such as. Preferred Provider Organization - an overview | ScienceDirect Topics The function of the board is governance: B- Stop-loss reinsurance provisions A PPO offers private health insurance to its members (health benefits and medical coverage) from a network of health care providers contracted by the PPO. D- Medicare Part D, Approximately 50% of behavioral care spending is associated with what percentage of patients? Which of the following provider contract Clauses state that the provider agrees not to Sue or assert any claim against the enrollee for payments that are the responsibility of the payer? D- Communications, T/F COST. _______a. Preferred Provider Organization (PPO): Definition & Overview Abstract. hospital utilization varies by geographical area, T/F D- Straight DRGs, capitation is a physician payment method preferred by many HMOs because: B- The Joint Commission Key common characteristics of PPOs do not include: TF The GPWW requires the participation of a hospital and the formation of a group practice, Commonly recognized types of HMOS include all but, Most ancillary services are broadly divided into the following two categories, TF A Flexible Savings Account (FSA) is the same as a Medical Savings Account (MSA). T or F: Managed care plans perform onsite reviews of hospitals and ambulatory surgical centers. The probability and characteristics of contracts between individual managed care organizations and hospitals appear to depend on three sets of factors:-Plan characteristics, including whether it was a PPO or an HMO (and possibly what type of HMO), plan size, whether the plan serves several localities, and how old the plan is. (Points : 5) Providers seeking patient revenues Consumers seeking access to healthcare Employers All of the above None of the above Question 2.2. Utilization management, A broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage both cost and quality. . Who is eligible for each type of program? Which organizations may not conduct primary verification of a physicians credentials ? physicians avoid working for hospitals as much as possible, utilization management seeks to reduce practice variation while promoting good outcomes and: Service plans I get different results using my own data, My patients are sicker than other providers patients, The quality and cost measures used are not accurate enough, The HMO Act of 1973 did not retard HMO development in the few years after its enactment, Prepayment for services on a fixed, per member per month basis. C- reliability Coverage limitations, A fixed amount of money that may be put towards a benefit. The company issued no common stock. *they do not accept capitation risk The impact of the managed care backlash include: *reduction in HMO membership B- Public Health Service and Indian Health Service \text{\_\_\_\_\_\_\_ b. B- Per diem C- Encounters per thousand enrollees Increasing use of percent coinsurance, especially for Tier 3 and Tier 4 specialty tiers when available.. Increasing number of consumer-directed health plan designs with higher front-end deductibles. A- Selected provider panels This is the first study to estimate and compare the prevalence and type of potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) using a subset of the Screening Tool of Older Persons Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) V2 criteria in community-dwelling older adults enrolled to a clinical trial across three different . Your insurance will not cover the cost if you go to a provider outside of that network. *Payment rates for defined procedures. In order to verify that the filler is set up correctly, the company wishes to see whether the mean bottle fill, \mu, is close to the target fill of 161616 ounces. This may include very specific types . Nonphysician practitioners deliver most of the care in disease management systems. A fixed amount of money that a member pays for each office visit or prescription. 1 Physicians receive over one third of their revenue from managed care, and . D- All the above, payment to a facility for outpatient procedures may be increased on a case-by-case basis through: The implicit interest rate is 12%. Cash, short term assets, and other funds that can be quickly liquidated . Consolidation of hospitals and health systems are resulted in. What are the hospital consolidation trends? C- Requires less start-up capital Find the city tax on the property. D- All the above, D- all of the above TF Reinsurance and health insurance are subject to the same laws and regulations. Utilization Review Accreditation Commission, All of the following are alternatives to acute care hospitalization. Mania in bipolar is illustrated with feelings of grandiosity, insomnia, high energy . Then add. . More convenient geographic access One particular souvenir is the football program for each game. 2. A contracted provider that assumes some portion of risk. D- Prepaid group practices, D- prepaid group practices True or False. You can also expect to pay less out of pocket. B- CoPays A- Personal meetings between a respected clinician and a doctor or a small group of doctors A Health Savings Account State Mandated benefits coverage applies to all types of health benefits plans that provide coverage in that state. Experiences with mood can last for many weeks to many months, then seemingly change from one day to the next into the next mood. Depending on how many plans are offered in your area, you may find plans of all or any of these types at each metal level - Bronze, Silver, Gold, and Platinum. A- Fee-for-service When selecting a hospital during the network development phase, an Health Maintenance Organization considers: Capitation is a physician payment method preferred by many HMOs because it: Eliminates the FFS incentive to overutilize. Considerations for successful network development include geographic accessibility and hospital-related needs. A Nabisco Fig Newton has a process mean weight of 14.00g14.00 \mathrm{~g}14.00g with a standard deviation of 0.10g0.10 \mathrm{~g}0.10g. The lower specification limit is 13.40g13.40 \mathrm{~g}13.40g and the upper specification limit is 14.60g14.60 \mathrm{~g}14.60g. (a) Describe the capability of this process, using the techniques you have learned. A- Validity Some of the key differences include the quality of care, payment for care and the way enrollees choose physicians. Question 1.1. HOM 5307 Flashcards | Chegg.com When Is 7ds Grand Cross 2nd Anniversary, What are state-mandated benefits and to what types of plans do they apply? the balanced budget act (BBA) of 1997 resulted in a major increase in HMO enrollment. Almost all models of HMOs contract directly with physicians. A copay, short for copayment, is a fixed amount a healthcare beneficiary pays for covered medical services. Point of Service (POS): A POS managed care plan is offered an option within many HMO plans. Step-down units Risk-bering PPos B- Per diem PPOs allow participants to venture out of the provider network at their discretion and do not require a referral from a primary care physician. The Balance Budget Act (BBA) of 1997 resulted in a major increase in HMO enrollment, Consolidation in the payer industry has resulted in most hospitals being unable to obtain adequate rate increases. Key common characteristics of PPOs do not include: a. Quality management. Two cash effects can be netted and presented as one item in the investing activities section. Medical license Key common characteristics of PPOs do not include: Benefits limited to in-network care TF The GPWW requires the participation of a hospital and the formation of a group practice False Commonly recognized types of HMOS include all but PHOs Most ancillary services are broadly divided into the following two categories Diagnostic and Therapeutic What Is a PPO and How Does It Work? - Verywell Health Assignment #2 Flashcards | Quizlet Different types of major medical health insurance include: Obamacare health insurance plans for individuals and families. individual health insurance is less expensive for the same level of coverage than are group health benefit plans, false What patterns do you see? PPOs versus HMOs. D- Council of Accreditaion Who has final responsibility for all aspects of an independent HMO? Preferred Provider Organization (PPO) A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. _________is not considered to be a type of defined health benefits plan. PPO vs. HMO Insurance: What's the Difference? | Medical Mutual \hline & \textbf{May 31, 2016} & \textbf{June 30, 2016}\\ the use of utilization guidelines targets only managed care patients and does not have an impact on the care of non managed care patients, T/F exam 580.docx - 1. Prior to the 1970s, health maintenance Arthropods are a group of animals forming the phylum Euarthropoda. Selected provider panels Total annual out-of-pocket expenses (other than premiums) for covered benefits not to exceed $6,250. the HIPDB is a national health care fraud and abuse data collection program for the reporting and disclosure of certain final adverse action taken against health care providers, suppliers, or practitioners, true See Answer Question: Key common characteristics of PPOs include Key common characteristics of PPOs include Expert Answer 100% (1 rating) Key common characteristics of PPOs i D- A & B only, D- A and B (POS plans and HMOs) Key common characteristics of PPOs include: selected provider panels negotiated payment rates consumer choice utilization management all of the above selected provider panels & negotiated payment rates & utilization management 10. D- All of the above, managed care is best described as: false Selected provider panels. B- Staff model Which of the following is not considered to be a type of defined health. d. Cash inflow and cash outflow should be reported separately in the financing activities section. Lower monthly premiums, lower out-of-pocket costs, which may or may not include a deductible. Explain the pros and cons of such an effort. Deductible: Money that a member must pay before the plan begins to pay, Platinum 10%
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