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Mod 6 Blues & MCO
Handbook Chap 11
| Question | Answer |
|---|---|
| MCO stands for what? | managed care organization |
| In addition to HMO's, other types of prepaid group practice models that use a managed care approach are operated by what? | MCO's - managed care organization |
| Capitation | a systgem of payment used by managed care plans in which physicians and hospitals are paid a fixed per capita amount for each patient enrolled over a stated period of time regardless of the type and # of services provided. |
| Medicare and Medicaid beneficiaries also may become members of what whether retired or employed? | managed care plans |
| primary care physician | also called gatekeeper; a physician who controls patient access to specialists and diagnostic testing services. |
| what was the usual method of billing by physicians in private practice before capitation? | fee-for-service |
| Name four types of HMO models | 1. Prepaid Group Practice Model 2. Staff Model 3. Network HMO 4. Direct Contract HMO |
| exclusive provider organization | type of managed care that combines features of HMO's and PPO's |
| foundation for medical care | an organization of physicians sponsored by a state or local medical association |
| Name two basic types of foundations for medical care operations | 1. comprehensive type 2. claims-review type |
| IPA | independent practice association; another type of MCO in which the physicians are not employees and are not paid salaries; paid by capitation or fee-for-service from premiums collected; a withhold is used to cover costs of operating the IPA |
| PPO | preferred provider organization; type of managed care plan where physicians provide services at a discount to patients who are members of the plan |
| POS | point of service plan - combines elements of HMO and a PPO while offering some unique features; allows patient to choose service from either an HMO provider or PPO provider |
| Provider-sponsored organization | PSO - managed care plan that is owned and operated by a hospital and provider group instead of an insurance company |
| If a medical plan is paid by the employer the plan is regulated by what? | ERISA - the employee retirement income security act - regulated by DOL |
| QIO | Quality Improvement Organization - performs reviews on medical necessity - formerly known as professional or peer review. |
| A peer review is an evaluation of what rendered by a practicing physician or physicians within a specialty group? | the quality and efficiency of services |
| carve out | medical services not included in the contract benefits - can be contracted for separately |
| preauthorization | required by some managed care plans for certain services or referral for patient to see a specialist. |
| What are 4 types of referrals? | 1. Formal referral 2. direct referral 3. verbal referral 4. self referral |
| True or False: In some managed care plans, when a PCP sends a patient to a specialist for consultation who is not in the plan, the specialist bills the PCP | True |
| a managed care plan where a specialist bills the PCP encourages PCP's to do what? | to not refer patients to specialists not on the plan so that he or she can retain profits |
| network facilities | many managed care plans require patients have lab or radiology studies performed at plan-specified facilities |
| copayment | fixed fee paid by the patient to the provider at the time of service |
| stop-loss limit | if a patient's services are more than a certain amount, the physician can begin asking the patient to pay for services. |
| withhold | in a managed care plan, is the percentage of the monthly capitation payment retained or percentage of the allowable charges to physicians until the end of the year to cover operating expenses |
| when a prepaid group practice plan limits the patient's choice of personal physicians this is termed what? | a closed panel program |
| in a managed care setting, a physician who controls patient access to specialists and diagnostic testing services is known as what? | gatekeeper or PCP |
| what are 3 systems that allow for better negotiations for contracts with large employers? | 1. Managed care organizations 2. physician hospital organizations 3. group practice accepting a variety of MCO's |
| the oldest type of the prepaid health plans is what? | HMO |
| name 4 type3s of HMO models | 1. Prepaid group practice model 2. staff model 3. network model 4. direct contract model |
| what is a foundation for medical care? | an organization of physicians sponsored by a state or local medical association concerned with the development and delivery of medical services and cost of health care. |
| name two types of operations used by a foundation of medical care | 1. comprehensive type-designs & sponsors prepaid health plans or sets of minimum benefits 2. claims review types - provides evaluation of the quality and efficiency of services |
| a health benefit program in which enrollees may choose any physician or hospital for services but obtain a higher level of benefits if preferred providers are used is known as what? | PPO |
| HMO's and PPO's consisting of a network of physicians and hospitals that provide an insurance company or employer with discounts on their services are referred to collectively as what | point of service |
| an organization that reviews medical necessity, reasonableness, appropriateness and completeness of inpatient hospital care is called what? | quality improvement organization or peer review |
| to control health care costs, the process of reviewing and establishing medical necessity for services and providers' use of medical care resources is called what? | utilization review |
| what is the meaning of a "stop-loss" provision that might appear in a managed care contract? | if the patient's services are more than a certain amount the physician can begin asking the patient to pay |
| quality improvement organization (QIO) does what? | 1. examines evidence for admission and discharge of a patient from the hospital 2. evaluates the quality and efficiency of services rendered by a practicing physician or physicians in a specialty group 3. settles disputes over fees |
| a type of managed care plan regulated unmder insurance laws combining features of HMO's and PPO's that employers agree not to contract with any other plan is known as what? | EPO -exclusive provider organization |
| medical services not included in a managed care contract's capitation rate but that may be contracted for separately are referred to as | carve outs |
| when the PCP informs the patient and telephones the referring physician that the patient is being referred for an appointment, this is called what? | verbal referral |
| plan-specified facilities listed in managed care plan contracts where patients are required to have lab and x-ray tests done are called what? | network facilities |
| True or False: an HMO can be sponsored and operated by a foundation | true |
| True or False: a quality improvement organization determines the quality and operation of health care | true |
| True or false: an employer may offer the services of an HMO clinic if he or she has five or more employees | false |
| True or False: Medicare and Medicaid beneficiaries may not join an HMO | false |
| True or false: withheld managed care amounts that are not yet received from the managed care plan by the medical practice should be shown as a write-off in an accounts journal | false |
Created by:
mpeoples