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MANAGED CARE

MBC-LESSON 3

QuestionAnswer
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)
Created by: Lizbeth Romo