The Balanced Budget Act (BBA) of 1997 resulted in a major increase in HMO enrollment, TF IPAs are intermediaries between a payer such as HMO, and its network physicians is, The "managed care backlash" resulted in (2) areas, A reduction in HMO membership and New federal & state laws and regulations, A fixed amount of money that a member pays for each office visit or Prescription, TF Employer Group Benefits Plans are a form of Entitlement Benefits Programs, Which of the following provider contract "clauses" state that the provider agrees not to sue or assert any claims against the enrollee for payments that are the responsibility of the payer, ______ is not used in the Affordable Care Act to describe a benefit level based on the amount of cost-sharing, TF Reinsurance and health insurance are subject to the same laws and regulations, What is not considered to be a type of defined health benefits plan, The ability of the payer to directly hire and fire a doctor, A percentage of the allowable charge that the member is responsible for paying is called, TF State mandated benefits coverage applies to all types of health benefits plans that provide coverage in that state is, Prior to the 1970s, organized health maintenance organizations (HMOs) such as Kaiser Permanente were often referred to as, Blue Cross began as a physician service bureau in the 1930s is, TF Managed care plans do not usually perform onsite credentialing reviews of hospitals and ambulatory surgical centers is, State network access (network adequacy) standards are, TF Health insurers and HMOs are licensed differently is, Consolidation of hospitals and health systems has resulted in, Basic elements of routine payer credentialing include all but which of the following, TF is the defining feature of a direct contract model HMO and the HMO is contracting directly with a hospital to provide acute services and to its members is, TF An IDS may not operate primarily as a vehicle for negotiating terms with private payers, Marketing Essentials: The Deca Connection, Carl A. Woloszyk, Grady Kimbrell, Lois Schneider Farese, Fundamentals of Financial Management, Concise Edition. True. nurse on call or medical advice programs are considered demand management strategies, T/F Medical Directors typically have responsibility for: Utilization management A patient has a sudden craving for ice cream induced by receiving a mild electrical stimulation to the hypothalamus. Compare and contrast the benefits of Medicare and Medicaid. As you progress in your major you probablyread about, this week you will locate ONE newspaper/magazine article via the Internet about a recent incident in your major course of study. 3. Medical Directors typically have responsibility for: You can use doctors, hospitals, and providers outside of the network for an additional cost. Which of the following is not considered to be a type of defined health benefits plan: State Mandated benefits coverage applies to all types of health benefits plans that provide coverage in that state. Is Mccormick Sloppy Joe Mix Vegan, TotalAssetsTotalLiabilitiesMay31,2016$188,000122,000June30,2016$244,00088,000. which of these is a fixed amount of payment per type of service? The characteristics of a medical expense or indemnity health insurance plan include deductibles, coinsurance requirements, stop-loss limits and maximum lifetime benefits. The following term refers to an all-inclusive rate paid by the HMO for both institutional and professional services: Behavioral change tools include all but which of the following? B- Per diem Subacute care Step-down units Outpatient facilities/units Home care Hospice care. Become a member and unlock all Study Answers Start today. the Health and Insurance Portability and Accountability Act limos the ability of health plans to: PPOs differ from HMOs because they do not accept capitation risk and enrollees who are willing to pay higher cost sharing may access providers that are not in the contracted network. PPOs differ from HMOs because they do not accept capitation risk and enrollees that are willing to pay higher cost sharing may access providers that are not in the contracted network, T/F In response, health insurers introduced "managed care," a series of options that manage the cost of healthcare and, thus, help employers keep premiums under control. B- Cost of services Study with Quizlet and memorize flashcards containing terms like Health insurance and Blue Cross Blue Shield plans can act as a third-party administrator, Identify which of the following comes the closest to describing a rental PPO also called a leased network, Key common characteristics of PPO does not include and more. Fastest Linebacker 40 Time, The bottling company wants to set up a hypothesis test so that the filler will be readjusted if the null hypothesis is rejected. Coinsurance: A percentage of the total of what the plan covers that the member is responsible for paying If you need mental health care, call your County Mental Health Agency. 16. There are different forms of hospital per diem . C- Utilization management D- Bed days per thousand enrollees, T/F recent legislature encourages separate different lifetime limits for behavioral care, T/F These include provider networks, provider oversight, prescription drug tiers, and more. 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. Coinsurance is: a. TF Employer Group Benefits Plans are a form of Entitlement Benefits Programs True 8. Then add. _______a. *they do not accept capitation risk D- Retrospective review, the most common measurement of inpatient utilization is: He hires an attorney to determine whether he and Mary were legally married. False Key common characteristics of PPOs include: False. C- Through the chargemaster D- Straight DRGs, capitation is a physician payment method preferred by many HMOs because: Oilwell_______b.Trademark_______c.Leasehold_______d.Goldmine_______e.Building_______f.Copyright_______g.Franchise_______h.Timberland_______i. 2.3+1.78+0.663. Medicare and Medicaid HMOs. -group health plans These are designed to manage . B- 10% 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. Trademark}\\ Key common characteristics of PPOs selected provider panels negotiated payment rates consumer choice utilization management The integral components of managed care are wellness and prevention primary care orientation utlilization management The original impetus of HMOs development came from Providers seeking patient revenues ), the original impetus of HMOs development came from: In contrast, PPOs tend not to require selection of a PCP, and you can usually see a specialist without a referral, and still have these costs covered. Utilization Review Accreditation Commission, All of the following are alternatives to acute care hospitalization. Home care is the defining feature of a direct contract model HMO and the HMO is Contracting directly with a hospital to provide acute service and two members. D- Medicare Part D, Approximately 50% of behavioral care spending is associated with what percentage of patients? This difference reveals contrasting views about the role government should play in protecting citizens from hunger, homelessness, and illness. B- Through a Resource Based Relative Value Scale PPOs feature a network of health care providers to provide you with healthcare services. 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. 2 points Key common characteristics of PPOs do NOT include: Limited provider panels O Discounted payment rates Consumer choice O Utilization management Benefits limited to in-network care. The function of the board is governance: overseeing and maintaining final responsibility for the plan. Category: HSM 546HSM 546 What Is PPO Insurance. Risk-bering PPos the term asymmetric knowledge as understood in the context of moral hazard refers to. C- Encounters per thousand enrollees Now they are living apart. In other words, consumer products are goods that are bought for consumption by the average consumer. Basic benefits that must be included in all Medicare supplement (medigap) policies include all the following EXCEPT: A: The first 3 pints of blood each year B: the part B percentage participation for. A contracted provider that assumes some portion of risk. commonly recognized types of HMOs include: who applies the various state and federal laws and regulations? SURVEY TOPICS. What will the attorney check first? Remember, reasonable people can have differing opinions on these questions. If a company has both an inflow and outflow of cash related to property, plant, and equipment, the. C- Reduced administrative costs, A- A reduction in HMO membership Figure 1 shows the percentage of beneficiaries by varying plan/carrier characteristics with combo benefit coverage in 2022. Regulators. C. Consumer choice. Improvement in physician drug formulary prescribing conformance, Reduction in drug interactions and resulting serious adverse effects, Reduction in prescribing and dispensing errors. Preferred Provider Organizations. (Look at fees every year, so you aren't undercharging, since medicare/Medicaid changes their allowable), ancillary services are broadly divided into which categories: An IDS can be described as a legal entity consisting of more than one type of provider to manage a populations health care and/or contract with a payer organization. Donald E. Kieso, Jerry J. Weygandt, Terry D. Warfield, Fundamentals of Financial Management, Concise Edition, Training Adaptations to Chronic Endurance Exe, Molecular Techniques and Clinical Relevance I. C- Case rate Defined benefits: health plan provides some type of coverage for specific medical goods and services, under particular circumstances Coverage limitations, A fixed amount of money that may be put towards a benefit. This may include very specific types . What are state-mandated benefits and to what types of plans do they apply? (TCO A) Key common characteristics of PPOs include _____. A- Cost increases 2-3 times the consumer price index Health plans with a Medicare Advantage risk contract. key common characteristics of PPOs include: A- Selected provider panels B- Negotiated payment rates C- Consumer choice & Utilization management D- All the above. Closed-Panel HMOs. The first important characteristic of PPO is that it allows its plan members to visit any doctor or hospital without referrals from the members' Primary Care Physicians (PCP). The purpose of managed care is to provide more people with health coverage limit the services of private insurance reduce the cost of health care and maintain the quality of care add more services to, Basic benefits that must be included in all Medicare supplement (medigap) policies include all the following EXCEPT: A: The first 3 pints of blood each year B: the part B percentage participation for, Write an essay compare and contrast the benefits of Medicare and Medicaid. What are the five types of people or organizations that make up the US healthcare system? commonly, recognized types of hmos include all but. UM (utilization management) focuses on traditional inpatient and ambulatory facility care, T/F Primary care orientation, A property has an assessed value of $72,000\$ 72,000$72,000. key common characteristics of PPOs include: -selected provider panels Which set of postoperative PPOs was used did not inu-ence the surgical procedure in any way. A PHO is usually a separate business entity requiring the participation of a hospital and at least some of the hospitals admitting physicians. Health care professionals that are not a part of the PPO are considered out-of-network. *new federal and state laws and regulations. What is the best managed care organization? D- Minutely scrubbing the data, A- personal meetings between a respected clinician and a doctor or a small group of doctors, T/F C- Carve-outs A- Improvement in physician drug formulary prescribing conformance the typical practicing physician has a good understanding of what is happening with his or her patient in between office visits, The least appropriate site for disease management is: B- Malpractice history B- HMOs Health Plan Employer Data and Information Set is the less widely used set of measures for reporting on managed behavioral health care. This has a negative impact on fruit quality for both industrial transformation and fresh consumption. B- Geographic location Government-sponsored plans that are created by state and local governments to provide managed care to Medicaid enrollees in a given geographical area. B- Primary care orientation C- Medical license How are outlier cases determined by a hospital? D- All the above, D- all of the above . C- Laboratory and therapeutic Selected provider panels. b. False Reinsurance and health insurance are subject to the same laws and regulations. *900 mergers. 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. The defining feature of a direct contract model is the HMO contracting directly with a hospital to provide acute services to its members. 7 & 5 & 6 & 6 & 6 & 4 & 8 & 6 & 9 & 3 Recent legislation encourages separate lifetime limits for behavioral care. PPOs allow participants to venture out of the provider network at their discretion and do not require a referral from a primary care physician. An IPA is an HMO that contracts directly with physicians and hospitals. Limited provider panels b. Bipolar disorder is a mental health condition in which a person shifts between mania, hypomania, and depression intermittently. What statement is true regarding the trends of traditional, non-specialty drugs (mostly oral and topical drugs dispensed in community pharmacy) and specialty drugs (biotech, injectables, high-cost orals)? From a marketing perspective, there are four types of consumer products, each with different marketing considerations. the managed care backlash resulted in which of the following: Hospice care, T/F When selecting a hospital during the network development phase, an Health Maintenance Organization considers: Occupancy rate C- Preferred Provider Organization 2.3+1.78+0.6632.3+1.78+0.663 Point-of-service (POS) plans are a type of Medicare managed care plan that acts as a hybrid HMO and PPO policy. false Orlando and Mary lived together for 14 years in Wichita, Kansas. PPOs tend to have higher monthly premiums in exchange for the flexibility to use providers both in and out of network without a referral. 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 Set up the null and alternative hypotheses for this hypothesis test. What are the key components of managed care? Bronze 40%, Medicare What are the hospital consolidation trends? 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. C- Laboratory tests The main characteristics of a PPO are: 1. health care providers contracted with the PPO are reimbursed on a fee-for-service basis; 2. A- Outreach clinic Extended inpatient treatment for substance abuse is clearly more effective, but too costly. Consumer choice State and federal regulations consistently apply network access standards to: Which of the following organizations may conduct primary verification of a physician's credentials? the integral components of managed care are: -wellness and prevention That's determined based on a full assessment. D- Sliding scale FFS, what are the basic ways to compensate open-panel PCPs? The term "managed care" is used to describe a type of health care focused on helping to reduce costs, while keeping quality of care high. Network Coverage. D- A array of health plans employers, unions, and other purchasers of care that attempt to manage cost, quality, and access to that care, A- A broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage cost, quality, and access to that care, prior to the 1970s, health maintenance organizations were known as: Payers which of the following is a basic benefit coverage? D- All the above, D- all of the above C- Mission clarity C- ICD-9 / ICD-10 codes True or False 7. A POS plan allows members to refer themselves outside the HMO network and still get some coverage. What type of health plan actually provides health care? Lower monthly premiums, lower out-of-pocket costs, which may or may not include a deductible. During their cohabitation, they both claimed to be married to one another. 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? Key common characteristics of PPOs do not include : a . \hline & \textbf{May 31, 2016} & \textbf{June 30, 2016}\\ T/F -primary care orientation These providers make up the plan's network. A- A broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage cost, quality, and access to that care Construct a graph and draw a straight line through the middle of the data to project sales. Add to cart. Nonphysician practitioners deliver most of the care in disease management systems. C- DRGs PPOs.). . Answer B refers to deductibles, and C to coinsurance. Experiences with mood can last for many weeks to many months, then seemingly change from one day to the next into the next mood. 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? c. A percentage of the allowable charge that the member is responsible for paying. 'health plan employer data and information set' is the less widely used set of measures for reporting on managed behavioral healthcare. What are the three core components of healthcare benefits? Most of these animals are bilaterally . D- A and B, how are outlier cases determined by a hospital? A provider entity assumes responsibility for the total costs of the Medicare Part A and B benefits for a defined population in a traditional Medicare fee-for-service program, with that entity sharing in any savings or losses relative to a target. B- Insurance companies a. . To apply for AIM, call 1-800-433-2611. Discussion of the major subsystems follows. The survey includes questions on the cost of health insurance, health benefit offer rates, coverage, eligibility, plan type enrollment, premium contributions, employee cost sharing . What is your view of government safety net programs ? growth mindset activities for high school pdf key common characteristics of ppos do not include D- none of the above, common sources of information that trigger DM include: Polyphenol oxidases (PPOs) catalyze the oxidization of polyphenols, which in turn causes the browning of the eggplant berry flesh after cutting. the major impetus behind the passage of the Affordable Care Act was: rising costs leading to more uninsured individuals. The cost-sharing provisions for outpatient surgery are similar to those for hospital admissions, as most workers have coinsurance or copayments. Personal meetings between a respected clinician and a doctor or a small group of doctors. (A. The characteristics of PPOs include flexibility and managed health care. Reinsurance and health insurance are subject to the same laws and regulations. \text{Total Liabilities} & 122,000 & 88,000 \\ 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 Lower cost. Commonly recognized types of HMOs include: a, b and d only (IPAs, Network, Staff and Group). Science Health Science HCM 472 Comments (1) Answer & Explanation Solved by verified expert Managed care is any method of organizing health care providers to achieve the dual goals of controlling health care costs and managing quality of care. Key common characteristics of PPOs include: Prepayment for services on a fixed, per member per month basis. b. Discounted payment rates c. Consumer choice d. Utilization management e. Benefits limited to in-network care c. Consumer choice 9. D- All the above, advantages of an IPA include: D- A & C only, basic elements of credentialing include: Inherent Vice may or may not include real Vice. They do not apply to self-funded benefits plans, Medicare or (usually) Medicaid. 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? 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 . Blue Cross began as a physician service bureau in the 1930s. The term moral hazard refers to which of the following. 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. 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. B- Discharge planning You can also expect to pay less out of pocket. T or F: Hospital consolidation has been blocked more often than not by the Department of Justice (DOJ) and/or the Federal Trade Commission (FTC). True or False 10. D- All the above, payment to a facility for outpatient procedures may be increased on a case-by-case basis through: The city property tax rate for this property is $4.12\$ 4.12$4.12 per $100\$ 100$100 of assessed valuation. Platinum b. 1. Green City Builders' balance sheet data at May 31, 2016, and June 30, 2016, follow: May31,2016June30,2016TotalAssets$188,000$244,000TotalLiabilities122,00088,000\begin{array}{lcc} B- More convenient geographic access 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). Coverage for Out-of-Network Care. Ammonia Reacts With Oxygen To Produce Nitrogen And Water, Which organization(s) need a Corporate Compliance Officer (CCO)? Cost sharing: some amount of a covered benefit is not paid by the plan but rather is paid out-of-pocket by someone covered under the benefit plan
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