Chapter 4 - Managed Care - Comprehensive (Alternate Care)

Front 1

The provision of comprehensive health services coordinated through a primary care provider, with emphasis on preventive care after the patient formally enrolls in a health care plan

Back 1

Managed Care

Front 2

PCP

Back 2

Primary Care Provider

Front 3

The PCP is a physician serving as a

Back 3

gatekeeper

Front 4

Coordinates all of the patients health care and decides what, if any, additional care or testing is required

Back 4

gatekeeper

Front 5

MCO

Back 5

Managed care organization

Front 6

Major types of MCO (managed care organization)

Back 6

1. HMO (health maintenance organizations)

2. PPOs (preferred provdier organizations)

3. indemnity insurance plans that have incorporated some managed care features

Front 7

Busniness entities that either arrange for or provide health services to an enrolled population after prepayment of a fixed sum of money, called a premium

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HMOs (health maintenance organizations)

Front 8

HMO is paid to keep who healthy?

Back 8

Patients

Front 9

Three characteristics to call oneself an HMO

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1. organized system for providing health care or otherwise assuring health care delivery in a geographic area

2. agreed-upon set of basic and supplemental health maintenance and treatment services

3. voluntarily enrolled group of people

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Most tightly organized HMO structure

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Staff Model

Front 11

All profits accrue to ______ rather than to the ________.

Back 11

1. HMO

2. physicians

Front 12

In Staff Model, how are physicians paid?

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Salary

Front 13

Exclusive contract with a multi specialty medical group that provides ALL physician services

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Group Model HMO

Front 14

Contracts with more than one physician group, hospital, and other facilities to provide comprehensive health care package

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Network Model HMO

Front 15

Developed primarily as a way for the solo practice physician to participate in the managed care market

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IPA (independent practice association)

Front 16

IPA HMO is formed by the physicians who are placing their own resources as the __________ ________.

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Start-up Funds

Front 17

Operates with two or more different types of organizational structures to provide flexibility to members, diversity of income to HMO, and attractive pricing to the employers.

Back 17

Mixed Model HMO

Front 18

When are Mixed Model HMOs sometimes created?

Back 18

Mergers and Acquisitions

Front 19

offered at a discounted rate in return for the promise of a higher volume of patients.

Back 19

PPOs

Front 20

pay little or no out of pocket expenses

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PPO patients

Front 21

industry term for traditional health insurance, in which the insured patient is reimbursed for expenses after the care has been given

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Indemnity Insurance

Front 22

Indemnity Insurance off has ________ and ______ responsibilities for the insured.

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1. deductible

2. Coinsurance

Front 23

The amount that the insureds must pay each year from their own pockets before the plan will make payments

Back 23

Deductible

Front 24

The portion of the cost for which the insured has financial responsibility, under an indemnity insurance policy, usually 20%..usually based on fixed percentages. (80/20%)

Back 24

Coinsurance

Front 25

Created to provide insureds with the freedom to choose their health care provider but also to control both premium levels and health care costs

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Managed Indemnity Plans

Front 26

Can incorporate any or all of the above managed care strategies.

Back 26

Point of Service Plan

Front 27

3 different consumer-directed health plans

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1. FSA (Flexible Spending Account)

2. HRA (Health Reimbursement)

3. HSA ( Health Saving Account)

Front 28

Account set up by the employee through his or her employer to cover health care costs. Amount is deposited into the account is predetermined by the employee on a pay-period basis, is pre-tax and any amount left in the account at the end of the benefit year is retained by the employer. "Use it or Lose it"

Back 28

FSA

Front 29

Created as part of the Medicare Modernization Act and permits individuals and families who purchase high deductible heath insurance coverage to contribute to the account.

Back 29

HSA

Front 30

Patients within a managed care organization are referred to as

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Members

Front 31

Another name for members

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Subscribers

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Spouse or child of the primary recipent

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Dependent

Front 33

Primary Recipent

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Subscriber/Member

Front 34

The primary care component of managed care uses

Back 34

physician extenders or mid-level providers to provide illness-related care

Front 35

Both assist the primary care physicians by performing preventive services such as a patient teaching and routine physical examinations, and by performing assessments of acute but non-life-threatening conditions for the physician

Back 35

Physicians Assistants (PAs)

Nurse Practitioners (NPs)

Front 36

Must practice under the direction of a physician and have their documentation reviewed and countersigned by the physician

Back 36

PAs

Front 37

Registered nurses who have received master's-level training in areas of specialty such as adult, family, or pediatric practice

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NPs

Front 38

Used in health plans to assist primary care providers in this portion of the misson

Back 38

Wellness Coordinators/Health educators

Front 39

Two types of regulatory organizations

Back 39

1. Governmental

2. Voluntary Accrediting

Front 40

takes place at federal and state levels, and concerned with care provided to enrollees of government programs, and the state regulation is concerned with the managed care organizations insurance license

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Governmental Regulation

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CLIA

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Clinical Laboratory Improvement Amendments of 1988

Front 42

Developed in response to concerns about potentially preventable deaths cause by poor PAP smear testing

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CLIA

Front 43

These laws very throughout the U.S. and are administered by the insurance commissioner's office or HMO regulatory agency in each state to ensure that the MCO is financially able to operate as an insurance company

Back 43

State Regulation

Front 44

MCO voluntary accreditation

Back 44

NCQA, TJC, AAAHC

Front 45

Formed in 1979 by the managed care industry

Back 45

NCQA

Front 46

The NCQA health plan accreditation standards include:

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1. Quality management and Improvement

2. Utilization Management

3. Credentialing and Re credentialing

4. Members' rights and responsibility

5. Standards for member connections

6. Performance Measures

Front 47

NCQA manages who?

Back 47

HEDIS

Front 48

Health plan accreditation standards for the HMOs and other integrated health plans; health network accreditation for PPOs

Back 48

URAC

Front 49

functions as the gatekeeper and writes orders for all diagnostic and therapeutic procedures that the PCP cannot perform

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Primary Care Provider

Front 50

usually a flat amount such as $10 per visit, made by the covered individual for a specific service at the time of the service

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Copayment

Front 51

The group of patients who have chosen the provider as their primary care provider

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Panel

Front 52

The payment of a fixed dollar amount for each covered person, for the provision of a predetermined set of health services for a specific period of time

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Capitation

Front 53

The capitation payment is usually made monthly, based on the monthly patient panel or assigned group of patients.

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PMPM (per member per month)

Front 54

Paid by the Day or at a Daily Rate

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Per Diem

Front 55

Per Diem are negotiated where?

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hospitals and skilled nursing facilities

Front 56

The MCO and the provider can negotiate a fee schedule for a flat rate per procedure, visit, or service

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Fee Schedule, Negotiated

Front 57

the use of unit value as the base and negotiate the conversion factory that provides appropriate reimbursement

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RBRVS

Front 58

form the basis of inpatient prospective payment system used by Medicare, some other payers, and some managed care organizations to reimburse acute care facilities

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DRGs

Front 59

Provider agrees to see MCO patients and charge the MCO the regular fee-for-service rate

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Discounted Charges

Front 60

Determining who the primary insurance payer is and ensuring that no more than 100 percent of the charges are paid to the provider and/or reimbursed to the patient

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Coordination of Benefits (COB)

Front 61

The most popular method used in determining the primary payer when both spouses carry insurance on the family is the

Back 61

birthday rule

Front 62

Two basic coding and classification systems

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ICD

HCPCS

Front 63

A component of a system for adjusting premiums paid to health plans based on the patient's health status

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Diagnosis Codes

Front 64

Model phased in as an initial mechanism for adjusting payments to Medicare managed care organizations based on patient diagnoses

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PIP-DCG (Principal In-Patient Diagnostic Cost Group

Front 65

Only ___ DRG assigned per stay

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One

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MCOs collect the DRG number or determine the number by entering the ICD-9-CM diagnosis and procedure codes into a special computer called

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grouper

Front 67

Revenue codes are collected on all claims submitted on

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UB-04 claim form

Front 68

HMO models that are able to collect encounter data on the patients they see in their clinics

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Staff and Group Model

Front 69

Hospitals within an MCO require a

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patient registration system

Front 70

allows the MCO to pay claims for authorized services and should verify the eligibility/enrollment files, benefit levels, and referral data before the payment is processed

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Claims Processing Software

Front 71

Core set of performance measures for managed care plans

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HEDIS

Front 72

Helps employers compare health plans, understand the value of what their health care purchasing and hold the health plan accountable for performance against these measures

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HEDIS

Front 73

HEDIS contains more than __ measures

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70

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Who is the quality plan developed by?

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Senior staff and approved by the board of directors, at least ANNUALLY

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Committee receives and reviews reports and project requests form subcommittees within the organizations

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Oversight Committee

Front 76

use a quantitative measuring tool for monitoring and evaluations performance

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Quality Indicators

Front 77

Measures how well the MCO is performing in comparison to preset goals

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Operational Effectiveness Indicators

Front 78

Express the MCOs ability to obtain a successful outcome from the care that is delivered. Also referred to as "outcome measures"

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Medical Indicators

Front 79

involves reviewing the necessity of an admission prior to its occurance

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Preadmission

Front 80

a review of elective procedures requiring prior approval for reimbursement

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preauthorization

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reviewing services ordered for medical necessity during an inpatient hospitalization before they are provided

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concurrent review

Front 82

arranging services that patients may require upon a discharge

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discharge planning

Front 83

Managed care is more comprehensive because of the wide variety of services provided under the managed care concept

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Risk Managment

Front 84

Unusual events are reported and tracked within

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MCO

Front 85

Unusual Events represent a primary source of _____

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litigation

Front 86

Performed to ensure that the provider is not under utilizing services and compromising the health of the member or over utilizing services and creating unnecessary expense

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Economic Credentialing

Front 87

Providers are credentialed every ____ years

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Two

Front 88

The HIM professional in managed care is found mainly in

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Staff Model

Group Model

Network Model

Front 89

These HMO settings require the HIM professional to...

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maintain security and confidentiality of records

Front 90

What coding systems would be used to code a hospital claim submitted to an MCO for payment?

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ICD

Front 91

What coding systems would be used for a physician’s claim?

Back 91

HCPCS

Front 92

How does an MCO perform coordination of benefits?

Back 92

It determines who the primary insurance payer is and ensures that no more than 100 percent of the charges are paid to the provider and/or reimbursed to the patient.

Front 93

What does the abbreviation PMPM mean, and why is it important in managed care?

Back 93

means per member per month / used to describe the amount of money paid for the monthly capitation rate per patient, a frequently used reimbursement method in managed care.

Front 94

What two benefits will the MCO realize from using on-line referral processing?

Back 94

allows them to direct patients to appropriate providers in the network / allows them to estimate future expenses associated with the referred care

Front 95

What contributed to the introduction of consumer-directed health plans?

Back 95

The employers need to curtail the double-digit premium increases they were experiencing every year, and the frustration that was felt by physicians and consumers over the restrictions and complexity of managed care.

Front 96

types of consumer-directed health plans

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Flexible spending account, Health ReimbursementArrangement, Health Savings Account

Front 97

tax-free money an employee sets aside to use during a specified period for health care expenses

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Flexible spending account (FSA)

Front 98

a mechanism by which an employer funds an account for its employees to pay for otherwise unreimbursed health care expenses

Back 98

Health Reimbursement Arrangement (HRA)

Front 99

an account set up by an employee w/ pretax income that is also not taxed when the employee withdraws from the account for medical expenses. Amounts left in the account at the end of the benefit year roll over to the next year. Withdrawals for non-medical expenses are subject to income tax and a 10 percent penalty!

Back 99

Health Savings Account (HSA)