Reimbursement Test 2 Part 1

rad2329's version from 2016-10-10 19:03

Section 1

Question Answer
How are Physicians reimbursed with a Preferred Provider Organization (PPO)?On a discounted fee-for-service basis
With this type of Health Maintenance Organization (HMO) Physicians are considered salaried employees instead of independent contractors ?Staff Model
Managed CareThey work to control the cost of, and access to, healthcare services at the same time they strive to meet high-quality standards.
A generic term for prepaid health plans that integrate the financial and delivery aspects of healthcare services.Managed Care
Managed Care Plans (Sayles page 703)A broad term used to describe several types of prepaid health care plans.
This legislation led to the development of investor-owned hospital chains and stimulated the growth of University Medical Centers?Medicare and Medicaid laws of 1965
Managed Care plans work to control ___?the cost of, and access to, healthcare services at the same time they strive to meet high-quality standards.
Cost Controlling MethodsReview of utilization of healthcare services (Makes sure services used wisely to control the costs).Using primary care physicians as gatekeepers to control referrals to specialists. Limit the providers from which the enrollee can seek treatment
Types of Managed Care PlansHealth Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs)
Health Maintenance Organization (HMO) premiums are based on ?A projection of the costs that are likely to be involved in treating the plan’s average enrollee over a specified time.
GROUP MODEL HMOsHMO enters into a contract with an independent multi-specialty group to provide services to the members of a plan. Providers agree to a fixed percentage of time to the HMO. HMO may own or directly manage the physician group (employees).Closed panel arrangements: Physicians not allowed to treat patients from other managed care plans. Enrollees are required to seek treatment from the designated physician group.
What is another name for an Independent Practice Associations (IPA) Individual practice associations
This organization manages and coordinates the delivery of healthcare services performed by a number of healthcare professionals and facilities and its physicians are salaried?Integrated Provider Organizations (IPO)

Section 2

Question Answer
HMOHealth Maintenance Organization
PPOPreferred Provider Organizations
POSPoint-of-Service Plans
EPOExclusive Provider Organizations
IDSIntegrated Delivery Systems
IPAModel of HMO is created when physicians join together in an organized group for the purposes of fulfilling a contract but retains individual practices
HMOThis is a prepaid voluntary health plan that provides healthcare services in return for the payment of a monthly membership premium.
PCPPrimary care physician
IPAIndependent Practice Associations
IPOIntegrated Provider Organization
PHOPhysician-Hospital Organizations

Section 3

Question Answer
Health Maintenance Organizations vs Fee for Service or other Managed CareOffered by most employers and insurance companies. Cost savings to enrollees as well as third-party payers. Enrollees enjoy significantly lower out-of-pocket expenses.Employer and enrollees have lower premiums.
Premiums are paid directly to this type of HMO, and services are usually provided within corporate facilities. Staff Model HMO
Types of Health Maintenance Organization (HMO) Models are ?Group Model - Independent Practice Association (IPA) - Staff Model - Network Model
Independent Practice Associations (IPAs)HMO enters into a contract with an organized group of physicians who join together for purposes of fulfilling the HMO contract but retain their individual practices. The physicians are not employees of the HMO
IPA is considered open-panel HMO which means ?That the physicians are free to treat patients from other plans. Enrollees of the HMO are required to seek services from the designated group.
The Health Maintenance Organization (HMO) will pay the Independent Practice Association (IPA) according to ?A negotiated list of discounted fees
Similar to a Group Model ?Network Model HMO
Network Model HMOTwo or more multi-specialty group practices. HMO contracts with two or more multi-specialty group practices instead of one.
Directly employ physicians and other healthcare professionals to provide medical services to membersStaff Model HMO
With this type of plan The subscribers must pay a greater share of the charges for out-of-network services ?Point-of-Service
Health care provider made up of a number of associated medical facilities that furnish coordinated healthcare services. Integrated Delivery Systems (IDS)
This is an arrangement that allows physicians to maintain their own offices, but to share administrative, management, and marketing services, (ie. Transcription, billing) for the purpose of fulfilling contracts with managed care organizations ?Group Practices with Walls
Medical foundations clinical assests and business assets ?Medical equipment, Supplies, Treatment facilities,Billing, Administrative support systems.

Section 4

Question Answer
With this type of Health Maintenance Organization (HMO), The physicians work from their own private offices and continue to see other patientsIndependent Practice Associations (IPAs)
Considered a closed panel HMO?Staff Model
Preferred Provider Organization (PPOs) have what type of agreements?Contractual agreements between healthcare providers and self-insured employer or health insurance carrier.
With this type Nonparticipating physicians can be chosen by beneficiaries, however this will come with a higher cost (ie. Higher deductible, co-pays)?Preferred Provider Organization (PPOs)
Definition of Physician-Hospital Organizations (PHOs)?They provide healthcare services through a contractual arrangement between physicians and hopsital(s).
Beneficiaries of Preferred Provider Organizations (PPOs) select providers such as physicians or hospitals from ?A list of participating providers who have agreed to furnish healthcare services to the covered population.
What would happen if the cost per HMO enrollee were actually to exceed the projected cost ?The HMO would experience a financial lost.
Exclusive Provider Organizations (EPOs) are regulated by ?State departments of commerce or departments of incorporation.
Types of Integrated Delivery Systems Models are ?Group practices without walls (GPWWs), Integrated Provider organization (IPOs), Management service organizations (MSOs), Medical Foundations, Physician-Hospital Organizations (PHOs).
With an Integrated Provider Organization (IPO) Physicians are ?Salaried employees
Definition of Management Service Organizations ? Provides practice management (administrative and support) services to individual physicians’ practices.
Definition of Medical Foundations?Nonprofit organizations that enter into contracts with physicians to mange the physician’s practices
Physician Hospital Organizations (PHOs) make it possible for the managed care market to view the hospital(s) and physicians as ?A single entity for the purpose of establishing a contract for services

Section 5

Question Answer
Point-of-Service Plans (POS) are similar to Health Maintenance Organizations (HMO) plans how?Subscribers must select a primary care physician (PCP) from a network of participating physicians
With Point of Service Plans POS) PCP a physician is usually a ?family physician, general practice, or internal medicine specialist.
The (Primary Care Provider (PCP) acts as a gatekeeper to control ?The patient’s access to specialty, surgical, and hospital care as well as expensive diagnostic tests.
How are Point of Service Plans (POS) different than Health Maintenance Organizations (HMOs) ?Allow subscribers to seek care from providers outside the network. This was done to provide greater flexibility and to allow the patients more choices in providers
Exclusive Provider Organizations (EPOs) are similar to Preferred Provider Organization (PPOs) how?Provide benefits to enrollees only when the enrollee receives healthcare services from Network providers. Services coordinated by a PCP.
Integrated Delivery System (IDS) facilities that provide services along the continuum of care are?Ambulatory surgery centers, Physician office practices, Outpatient clinics, Acute care hospitals, SNFs, Home Health, Hospice, etc.
Integrated Provider Organizations (IPOs) do what ?Manage and coordinate the delivery of healthcare services performed by a number of healthcare professionals and facilities.
Integrated Provider Organizations (IPOs) are also known as ?“delivery systems”, “horizontally integrated systems”, “health delivery networks”, “accountable health plans”, “integrated service networks (ISNs)” “Vertically integrated plans (VIPs), and “vertically integrated systems.”
Management Service Organizations are owned by ?A group of physicians or a hospital
Medical foundations Own ? Clinical and business resources and makes them available to the participating physicians
Physician-Hospital Organizations (PHOs) were previously known as ?Medical staff-hospital organizations.
With a Preferred Provider Organization (PPO) Nonparticipating physicians can be chosen by beneficiaries, however this ?Will come with a higher cost (ie. Higher deductible, co-pays)

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