PPOs continue to be the most common type of plan . 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)? Category: HSM 546HSM 546 D- All the above, D- all of the above (creation of western clinic in Tacoma, WA. T/F \text{\_\_\_\_\_\_\_ i. Identify examples of the types of defined health benefits plan: *individual health insurance Payment to a facility for outpatient procedures may be increased on a case-by-case basis through which of the following? State and federal regulations consistently apply network access standards to: Which of the following organizations may conduct primary verification of a physicians credentials? E- All the above, which of the following is a typical complaint healthcare providers have about health plan provider profiling? managed care plans perform onsite reviews of hospitals and ambulatory surgical centers, T/F physicians avoid working for hospitals as much as possible, utilization management seeks to reduce practice variation while promoting good outcomes and: UM focuses on telling doctors and hospitals what to do. extended inpatient treatment for substance abuse is clearly more effective, but too costly, T/F In 2022, MA rules allow plans to cover up to three packages of combo benefits. false In the medical management area, committees serve to diffuse some elements of responsibility and allow important input from the field into procedure and policy or even into case-specific interpretation of existing policy. C- reliability A- Enrollees per thousand bed days A patient has a sudden craving for ice cream induced by receiving a mild electrical stimulation to the hypothalamus. T or F: In the medical management area, committees serve to diffuse some elements of responsibility and allow important input from the field into procedure and policy or even into case-specific interpretation of existing policy. consolidation in the payer industry has resulted in most hospitals being unable to obtain adequate rate increases, false key common characteristics of ppos do not include 0. B- More convenient geographic access 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. \text{\_\_\_\_\_\_\_ h. Timberland}\\ Orlando and Mary lived together for 14 years in Wichita, Kansas. (PPOs) administer the most common types of managed care health insurance plans. A- Outlier Open-access HMOs PPOs pay physicians FFS, sometimes as a discount from usual, customary, and reasonable (VCR) charges, and sometimes with a fee schedule. The least appropriate site for disease management is: The GPWW requires the participation of a hospital and the formation of a group practice. hospital utilization varies by geographical area, T/F State laws may require health plans to cover the costs of certain defined types of care and services as well as services provided by certain types of providers 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. Medical Directors typically have responsibility for: Nurse-on-call or medical advice programs are considered demand management strategies True or False, It is possible for a specialist to also act as a primary care provider. A- Hospital privileges The ability of the pair to directly hire and fire a doctor. *Pace quickened (A. (POS= point of service), which organization may conduct primary verification of a physician's credentials? 1. (TCO B) The original impetus of HMO development came from which of the following? What are the two types of traditional health insurance? 7566648693. No-balance-billing clause Force majeure clause Hold-harmless clause 2. Most ancillary services are broadly divided into the following two categories. Hospitals purchased physician practices and employed physicians in the 1990s, but will no longer do so. The implicit interest rate is 12%. Health insurers and Blue Cross and Blue Shield plans can act as third-party administrators. The HMO Act of 1973 did contributed to the growth of managed care. D- All the above, advantages of an IPA include: A- Utilization management Negotiated payment rates. the balanced budget Act of 1997 resulted in major increase in HMO enrollment. Nonphysician practitioners deliver most of the care in disease management systems. A growing number of the drugs in the pipeline for FDA approval are injectable products and the specialty drug trend, already at 20%, is expected to increase. what, Please reflect on these three questions and answer them thoughtfully. a specialist can also act as a primary care provider, T/F Inherent Vice may or may not include real Vice. B- Public Health Service and Indian Health Service Competition and rising costs of health care have even led . A Medical Savings Account 2. In markets with high levels of managed care penetration, hospitals are usually paid using a sliding scale discount on charges method. What are the basic ways to compensate open-panel PCPs? Hospitals & 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. Oilwell_______b.Trademark_______c.Leasehold_______d.Goldmine_______e.Building_______f.Copyright_______g.Franchise_______h.Timberland_______i. Hospital consolidation has been blocked more often than not by the Department of Justice (DOJ) and/or the Federal Trade Commission (FTC). Which set of postoperative PPOs was used did not inu-ence the surgical procedure in any way. Which of the following is a typical complaint providers have about health plan provider profiling? Abstract. key common characteristics of ppos do not include Non-risk-bearing PPOs Defined benefits: health plan provides some type of coverage for specific medical goods and services, under particular circumstances B- Per diem C. Consumer choice. 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. Payers The probability and characteristics of contracts between individual managed care organizations and hospitals appear to depend on three sets of factors:-Plan characteristics, including whether it was a PPO or an HMO (and possibly what type of HMO), plan size, whether the plan serves several localities, and how old the plan is. (Points : 5) Providers seeking patient revenues Consumers seeking access to healthcare Employers All of the above None of the above Question 2.2. The Court held that the law was a prior restraint on freedom of speech and of the press under the 1st Amendment. individual health insurance is less expensive for the same level of coverage than are group health benefit plans, false cost of non catastrophic, recurring outpatient care has risen significantly in the past few decades, T/F \end{matrix} 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. HSA4109 Chapters 1-3 Flashcards | Quizlet Key common characteristics of PPOs include: a, b and d only (Selected provider panels, Negotiated payment rates, Utilization management) Commonly recognized types of HMOs include: a, b and d only (IPAs, Network, Staff and Group) An IPA is an HMO that contracts directly with physicians and hospitals. An IPA is an HMO that contracts directly with physicians and hospitals. 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. D- A and B, how are outlier cases determined by a hospital? *The "dual choice" provision required employers with 25 or more employees that offer indemnity coverage to also offer at least one group or staff model and one IPA-model HMO, but only if the HMOs formally requested to be offered. They apply to coverage for which the insurer or HMO is at risk for medical costs, and which is licensed by the state. D- Bed days per thousand enrollees, T/F 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 . When selecting a hospital during the network development phase, an Health Maintenance Organization considers: Occupancy rate Patients Wellness and prevention, growth mindset activities for high school pdf key common characteristics of ppos do not include Compare and contrast the benefits of Medicare and Medicaid. A PPO is an organization that contracts with health care providers who agree to accept discounts from their usual and customary fees and comply with utilization review policies in return for the patient flow they expect from the PPO. -more convenient geographic access Q&A. A- 5% B- Through a Resource Based Relative Value Scale D- A & B only, T/F The enrollees may go outside the network, but would incur larger costs in the form of higher deductibles, higher coinsurance rates, or non- Managed Care and HMOs. \text{Total Liabilities} & 122,000 & 88,000 \\ Find common denominators and subtract. True. peer pressure works through "shaming" physicians into changing behavior, Behavioral change tools include all but which of the following? HMO vs. PPO: Differences, Similarities, and How to Choose - GoodRx Coverage for Out-of-Network Care. Cash inflow and cash outflow should be reported separately in the investing activities section. C- Short Stay clinic selected provider panels negotiated payment rates consumer choice utilization management All of the above A, B, and D only 3. D- none of the above, common sources of information that trigger DM include: Preferred Provider Organization (PPO) A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. True. 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. 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: T/F 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. D- All the above, D- all of the above Benefits determinations for appeals 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, Health plans with a Medicare Advantage risk contract only, The integral components of managed care are. Lakorn Galaxy Roy Leh Marnya, E- All the above, T/F A- Group model Money that a member must pay before the plan begins to pay. Who has final responsibility for all aspects of an independent HMO? PPOs are the most common type of health insurance plan offered by employers with 71% of the employers surveyed providing this type of plan to all or most of their workers, followed by high-deductible health plans (41%) and HMOs (28%), according to XpertHR's 2021 Employee Benefits Survey.. Employees often have a choice of several plans. was the first HMO. HMOs are licensed as health insurance companies. He has fallen in love with another woman and plans to marry her. Governments in Canada and many nations in Europe provide their citizens with far more benefits than the U.S. government provides to its citizens. 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? 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. Course Hero is not sponsored or endorsed by any college or university. Managed Care - Boston University True or False. Blue Cross began as a physician service bureau in the 1930s. PPO plans have three defining characteristics. A flex saving account is the same as a medical savings account. When Is 7ds Grand Cross 2nd Anniversary, a broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage both cost and quality the Health and Insurance Portability and Accountability Act limos the ability of health plans to: -deny insurance based on health status -exclude coverage of preexisting conditions What are the hospital consolidation trends? T/F Direct contracting refers to direct contracts between the HMO and the physicians. PPOs generally offer a wider choice of providers than HMOs. Establishing a high level of evidence regarding disease management guidelines ensures: Value-based insurance designs that assign high-value drugs to Tier 1 for ALL therapeutic categories. 5 - A key difference between an HMO and a PPO is that the latter provides enrollees with more flexibility to see providers outside of the plan's provider network, although cost sharing . Limited provider panels b. Almost all models of HMOs contract directly with physicians. Utilization Review Accreditation Commission, All of the following are alternatives to acute care hospitalization. D- All the above, C- through the chargemaster Cost increases 2-3 times the consumer price index, Potential for improvements in medical management, Third-party consultants that specialize in data analysis and aggregate data across health plans. A- Costs are predictable A- Wellness and prevention What types of countries dominate these routes? 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. 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. -requires less start-up capital recent legislature encourages separate different lifetime limits for behavioral care, T/F test 1 morning tiggle Flashcards | Quizlet 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. B- Is less costly to administer than FFS COST. 28 related questions found What is a PPO plan? Is Mccormick Sloppy Joe Mix Vegan, C- Prospective review A- A PPO Ancillary services are broadly divided into the following categories: Hospital privileges Some. D- A & C only, basic elements of credentialing include: Subacute care Step-down units Outpatient facilities/units Home care Hospice care. Compared to PPOs, HMOs cost less. Considerations for successful network development include geographic accessibility and hospital-related needs. key common characteristics of ppos do not include. It paid cash dividends of7,500ofcommonstockandpaidnodividends.b.Thecompanyissuednocommonstock.Itpaidcashdividendsof 13,000. PPO (Preferred Provider Organization) PPO plans are among the most common types of health insurance plans. All three of these methods are used to manage utilization during the course of a hospitalization: Utilization management. B- Stop-loss reinsurance provisions Step-down units Health Maintenance Organization - HMO: A health maintenance organization (HMO) is an organization that provides health coverage for a monthly or annual fee. The characteristics of PPOs include flexibility and managed health care. A- Claims A- Point-of-service programs Mon-Fri 9:00AM - 6:00AM Sat - 9:00AM-5:00PM Sundays by appointment only! Nearly three fourths of privately insured Americans now receive network-based health care through health maintenance organizations (HMOs), preferred provider organizations (PPOs), and various point-of-service hybrid arrangements. A contracted provider that assumes some portion of risk. In what model does an HMO contract with more than one group practice provide medical services to its members? Service plans Arthropods are a group of animals forming the phylum Euarthropoda. 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. What has been the benefit for both sets of individuals who are the. Which organization(s) accredit managed behavioral health care companies? most of the care in disease management systems is delivered in inpatient settings since the acuity is much greater, T/F
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