Open-access HMOs D- All the above, 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? A- Analytics 2.3+1.78+0.663. A- POS plans 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 board of directors has final responsibility for all aspects of an independent HMO. HSM 546 W1 DQ2 ManagedCare Plans quantity. B- Is less costly to administer than FFS A- Through cost-accounting Who has final responsibility for all aspects of an independent HMO? The cost-sharing provisions for outpatient surgery are similar to those for hospital admissions, as most workers have coinsurance or copayments. UM focuses on telling doctors and hospitals what to do, false Hospitals & These providers make up the plan's network. The United States does not have a universal health care delivery system enjoyed by everyone. A- Wellness and prevention When selecting a hospital during the network development phase, an Health Maintenance Organization considers: Occupancy rate B- Staff model the major impetus behind the passage of the Affordable Care Act was: rising costs leading to more uninsured individuals. Hospital utilization varies by geographical area. the original impetus of HMOs development came from: The balance budget act of 1997 resulted in a major increase in Medicare HMO enrollment, the growth of PPOs led to the development of HMOs, in the 1980's and 1990's managed care grew rapidly while traditional indemnity health insurance declined, a broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage both cost and quality. How a PPO Works. Payers More convenient geographic access Employers are usually able to obtain more favorable pricing than individuals can Coinsurance: A percentage of the total of what the plan covers that the member is responsible for paying You pay less if you use providers that belong to the plan's network. Which organization(s) need a Corporate Compliance Officer (CCO)? A Health Maintenance Organization (HMO . Patients PPO plans have three defining characteristics. D- Prepaid group practices, D- prepaid group practices There are four main types of managed health care plans: health maintenance organization (HMO), preferred provider organization (PPO), point of service (POS), and exclusive provider organization (EPO). 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)? A provider Network that contracts with various payers to provide access and claims repricing. The implicit interest rate is 12%. C- Prepaid practices Which of the following is not considered to be a type of defined health. Key common characteristics of PPOs include: Selected provider panels. Samson Corporation issued a 4-year, $75,000, zero-interest-bearing note to Brown Company on January 1, 2020, and received cash of$47,664. D- All the above, T/F A- Providers seeking patient revenues fee for service payment is the most common method used by HMOs to pay for specialists, T/F Key common characteristics of PPOs include: selected provider panels negotiated payment rates consumer choice utilization management all of the above selected provider panels & negotiated payment rates & utilization management 10. Pre-certification that includes the authorized coverage length of stayConcurrent, or continued stay, review by UM nurses using evidence-based clinical criteriaDischarge planning prior to admission or at the beginning of the stay. key common characteristics of ppos do not include benefits limited to in network care The GPWW requires the participation of a hospital and the formation of a group practice. D- A & B only, T/F (TCO B) The original impetus of HMO development came from which of the following? Blue SHIELD began as a physician service bureau in 1939 while Blue CROSS began in 1929 as a hospital, T/F C- Consumers seeking access to health care 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. Limited provider panels b. Bipolar disorder is a mental health condition in which a person shifts between mania, hypomania, and depression intermittently. Answer B refers to deductibles, and C to coinsurance. 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. D- Council of Accreditaion C. Consumer choice. D- All the above, D- all of the above acids and proteins). PPOs continue to be the most common type of plan . key common characteristics of PPOs include: -selected provider panels E- All the above, T/F A- Fee-for-service PPOs versus HMOs. In order to, During your studies at the College you are taking classes to learn about your major course of study as preparation to enter your future career. What specific factors other than diseases commonly affect severity of illness? 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. D- All the above, advantages of an IPA include: C- Encounters per thousand enrollees HDHP (CDHP) (For example, coverage cannot be denied because of a pre-existing condition such as cancer.) Health insurers and Blue Cross and Blue Shield plans can act as third-party administrators. B- Ambulatory care setting D- none of the above, common sources of information that trigger DM include: There are different forms of hospital per diem . D- All the above, Which organization(s) need a Corporate Compliance Officer (CCO)? the most effective way to induce behavior changes in physician is through continuing medical education, T/F 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. D- Retrospective review, the most common measurement of inpatient utilization is: Statutory capital is best understood as. B- Capitation These include provider networks, provider oversight, prescription drug tiers, and more. Mania in bipolar is illustrated with feelings of grandiosity, insomnia, high energy . Then add. Apply Concepts In the case Burs tyn, Inc. v. Wilson , 1952, the Supreme Court voided a New York law that allowed censors to forbid the commercial showing of a motion picture that it had decided was "sacrilegious." 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. Is Orlando free to marry another? the majority of prescriptions for behavioral health medications are written by non-psychiatrists, T/F 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. Defined benefits: health plan provides some type of coverage for specific medical goods and services, under particular circumstances In the United States, we have a private and competitive health insurance system which will cause managed care to continue to evolve. Health Maintenance Organization - HMO: A health maintenance organization (HMO) is an organization that provides health coverage for a monthly or annual fee. Board Exams. Consolidation of hospitals and health systems are resulted in. HMO plans typically have lower monthly premiums. . Make a comparison of a free enterprise system's benefits and disadvantages. A reduction in HMO membership and new federal and state regulations. T/F PPOs versus HMOs. *medicare What is an appeal? C- State Medicaid programs Characteristics of group health insurance include: true group plan-one in which all employees must be accepted for coverage regardless of physical condition. nonphysician practioners deliver most of the care in disease management systems, T/F 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. PSO commonly recognized types of HMOs include (a,b, and d only) IPAs, network, staff and group B- Primary care orientation provider as with an HMO, but you also get to visit out-of-network providers as with a PPO. Which of the following accounts does a manufacturing company have that a service company does not have? A- Group model A- Bundled payment bluecross began as a physician service bureau in the 1930s A- Claims C- Reducing access The purpose of this research paper is to compare health care systems in three highly advanced industrialized countries: The United States of America, Canada and Germany. (b) Would you think that further variance reduction efforts would be a good idea? A POS plan allows members to refer themselves outside the HMO network and still get some coverage. Identify the following assets a through i as reported on the balance sheet as intangible assets (IA), natural resources (NR), or other (O). Saltmine. 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: Different types of major medical health insurance include: Obamacare health insurance plans for individuals and families. On IDs may not operate primarily as a vehicle for negotiating terms with private payers. E- All the above, which of the following is a typical complaint healthcare providers have about health plan provider profiling? Two cash effects can be netted and presented as one item in the investing activities section. The Public-Private Partnership Legal Resource Center (PPPLRC) formerly known as Public-Private Partnership in Infrastructure Resource Center for Contracts, Laws and Regulations (PPPIRC) provides easy access to an array of sample legal materials which can assist in the planning, design and legal structuring of any infrastructure project especially a project which involves a public-private . Like virtually all types of health coverage, a PPO uses cost-sharing to help keep costs in check. 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? B- Reduction in drug interactions and resulting serious adverse effects