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MANAGED CARE
MBC-LESSON 3
Question | Answer |
---|---|
What does PMPM stand for in managed care contracts? | Per member per month payment based capitation |
What is the most restrictive type of managed care plan: | HMO |
Which managed care plan type does not use a network of providers? | Indemnity Plan |
What were the federal funds used for in the HMO act of 1973? | To promote health maintenance organizations, HMOs |
What are the goals of managed care? | To control healthcare costs and manage quality care |
What did the employers do to avoid higher costs of healthcare in the past? | Hire temporary employees who will not be eligible for health insurance benefits to avoid high costs. |
What is the term used to refer to fees in an insurance contract? | UCR, Usual, customary, and reasonable fees |
What are utilization guidelines used for? | To deny medical services to patients, so providers would determine the medical necessity of tests and services before providing them. |
To determine the amount due from a patient, what must the medical office specialist know? | Must know the billed allowed amount, contractual amount and patient co-pay portion. |
Who qualifies for COBRA benefits? | If the insured works for a business of 20 or more employees and leaves his job or is laid off. Children who are full time students. |
How many employees must the employer have to offer COBRA benefits? | 20 or more employees. |
What type of insurance coverage provides protection against a certain type of accident or illness? | Special Risk |
What is the common type of payment arrangement in a managed care contract? | Discount fee-for-service, usual and customary, and capitated payments. |
A managed care contract is considered a legal document between whom? | The provider and the health care management, |
A medical office specialist works as a liaison between ? | The provider and the patient, the provider and the carrier |
What does the schedule of benefits section include? | A list of medical services covered under the insured's policy and the amount paid. |
What is the fee schedule in managed care contracts increasingly based on? | Medicare's resource-based relative value scale RBRVS with a different conversion factor |
What does RBRVS stand for? | Resource-based relative value scale. |
During the credentialing process, a managed care organization evaluates what about the provider? | Medical credentials, service fees, and workplace environment. |
What is the organization that awards accreditation to managed care organizations? | National Committee for Quality Assurace (NCQA) |