HCD Midterm!!! || 100% Verified Answers.
what can be used for recruitment of employees and providers to rural areas of practice? correct
answers managed care organizations
when did MCO's begin to expand? correct answers during WWII
HMO act of 1973 correct answers required employers with more than 25 employees to offer this
type of plan if traditional plans were offered
when did the requirement to offer HMOs expire correct answers 1990's
why was there such a decrease in the 90's/2000 in enrollment in HMOs? correct answers because
of the unaffordability and falling out of favor with those eligible for the plan .
functions of managed care correct answers administrative , underwriting, and delivery
administrative functions of MCO correct answers premiums based on contract negotiations
between employers and mCO
underwriting functions of MCO correct answers organization takes the financial responsibility if
total cost of services provided exceeds revenue from fixed premiums
what does fixed premium per enrollee include correct answers all health care services provided
for in the contract
delivery function of MCO correct answers organization promises to provide a comprehensive set
of services by contracting arrangements with physicians, clinics, and hospitals (network of
providers)
how do MCO's acquire enrollees ? correct answers through the use of market strategy
Are MCO's required to become accredited? correct answers NO! NO! NO! VOLUNTARY
what are the 3 agencies that accredit HMOs or PPOs correct answers The Joint Commission,
national committee for quality assurance NCQA, and the Utilization Review for Accreditation
Commission URAC
what accreditation standards do HMOS follow correct answers NCQA
what accreditation standards do PPOs follow correct answers URAC
how does NCQA promote performance standards and quality assurance correct answers HEDIS
what does MCO quality assessment involve? correct answers structure, process, and outcomes
,the seven essential features of MCOs correct answers -cost containment , accountability for
quality of care, measurement of health outcomes ,and quality of care, health promotion and
disease management programs, management of resource consumption , consumer education
programs , and continuing quality improvement
how does MCO control costs correct answers through eliminating insurance an payer
intermediaries , sharing risk with providers, extracting discounts from providers, coordinating a
patient services and monitoring care to determine appropriateness and cost effectiveness
what are the strategies MCO use to monitor care, determine appropriate care , and cost
effectiveness correct answers choice restrictions , case management, practice profiling, gate
keeping, and utilization review
choice restrictions for monitoring and controlling cost of MCO correct answers the physician is
an employee of the MCo or has a contract with the MCO and is on the MCO panel which can be
closed , in network panel , or an open , out of network panel
gate keeping for monitoring and controlling cost of MCO correct answers when the PCP
coordinates all health care services with an emphasis on preventative care, routine physical
exams. The PCP refers the patient to a consultation with a specialist , overall controlling the
patients utilization of healthcare
Case management for monitoring and controlling cost of MCO correct answers an experienced
health care professional with knowledge of available resources monitors the patients care along
with the case manager to create a cost effective and efficient care plan for the patient
utilization review for monitoring and controlling cost of MCO correct answers assessing the
appropriateness of the services provided to the patients .
The utlization review process includes correct answers reviewing each patient's case to determine
the level of services appropriate , the setting the delivery of services will take place , determine
the most cost effective method ,and the need for followup/subsequent care
what are the two types of utilization review correct answers prospective and retrospective
prospective UR correct answers appropriateness of care is determined before the care is
delivered
retrospective UR correct answers managing services after care is already delivers by reviewing
medical records
practice profiling for monitoring and controlling cost of MCO correct answers used to decide
which providers have the right fit with the plans managed care philosophy and goals and is also
used to give feedback to providers so they can modify their own behavior of medical practice
, practice profiling with MCO correct answers is also know as profile monitoring , and is the
development of provider -specific practice patterns and comparisons of individual practice
patterns to some norm
MCO provider payment mechanisms include correct answers capitation, salaries, and discounted
fee
capitation correct answers is when the provider is paid a fixed monthly sum per enrollee, often
call per member per month payment PMPM
salaries correct answers is when the provider is paid , including bonuses or withholdings ,
provider=employee of MCO
discounted fee correct answers is when the provider is paid after the services have been delivered
to the patient . The provider can bill the MCo for each service separately but is paid according to
the pre-negotiated discount schedule (fee schedule)
what are the types of managed care organizations correct answers HMO, PPO, EPO, POS
what are the HMO types correct answers staff HMO, group HMO, network HMO, independent
practice association IPA
HMO stands for correct answers health maintenance organization
PPO stands for correct answers preferred provider organization
EPO stand for correct answers exclusive provider organization
POS stands for correct answers Point of service
what are the differing characteristics of managed care plans correct answers risk bearing ,
physician type, out of network coverage , relationship exclusivity
what 2 managed care plans have out of network coverage correct answers PPO and POS
what 2 managed care plans have exclusivity of relationship correct answers HMO STAFF and
HMO GROUP
what 2 managed care plans have large groups of physician types correct answers HMO GROUP
AND HMO NETWORK
what 3 managed care plans have physician risk bearing correct answers HMO GROUP, HMO
NETWORK , AND IPA
when did HMO enrollment gro rapidly correct answers first half of the 90's
what can be used for recruitment of employees and providers to rural areas of practice? correct
answers managed care organizations
when did MCO's begin to expand? correct answers during WWII
HMO act of 1973 correct answers required employers with more than 25 employees to offer this
type of plan if traditional plans were offered
when did the requirement to offer HMOs expire correct answers 1990's
why was there such a decrease in the 90's/2000 in enrollment in HMOs? correct answers because
of the unaffordability and falling out of favor with those eligible for the plan .
functions of managed care correct answers administrative , underwriting, and delivery
administrative functions of MCO correct answers premiums based on contract negotiations
between employers and mCO
underwriting functions of MCO correct answers organization takes the financial responsibility if
total cost of services provided exceeds revenue from fixed premiums
what does fixed premium per enrollee include correct answers all health care services provided
for in the contract
delivery function of MCO correct answers organization promises to provide a comprehensive set
of services by contracting arrangements with physicians, clinics, and hospitals (network of
providers)
how do MCO's acquire enrollees ? correct answers through the use of market strategy
Are MCO's required to become accredited? correct answers NO! NO! NO! VOLUNTARY
what are the 3 agencies that accredit HMOs or PPOs correct answers The Joint Commission,
national committee for quality assurance NCQA, and the Utilization Review for Accreditation
Commission URAC
what accreditation standards do HMOS follow correct answers NCQA
what accreditation standards do PPOs follow correct answers URAC
how does NCQA promote performance standards and quality assurance correct answers HEDIS
what does MCO quality assessment involve? correct answers structure, process, and outcomes
,the seven essential features of MCOs correct answers -cost containment , accountability for
quality of care, measurement of health outcomes ,and quality of care, health promotion and
disease management programs, management of resource consumption , consumer education
programs , and continuing quality improvement
how does MCO control costs correct answers through eliminating insurance an payer
intermediaries , sharing risk with providers, extracting discounts from providers, coordinating a
patient services and monitoring care to determine appropriateness and cost effectiveness
what are the strategies MCO use to monitor care, determine appropriate care , and cost
effectiveness correct answers choice restrictions , case management, practice profiling, gate
keeping, and utilization review
choice restrictions for monitoring and controlling cost of MCO correct answers the physician is
an employee of the MCo or has a contract with the MCO and is on the MCO panel which can be
closed , in network panel , or an open , out of network panel
gate keeping for monitoring and controlling cost of MCO correct answers when the PCP
coordinates all health care services with an emphasis on preventative care, routine physical
exams. The PCP refers the patient to a consultation with a specialist , overall controlling the
patients utilization of healthcare
Case management for monitoring and controlling cost of MCO correct answers an experienced
health care professional with knowledge of available resources monitors the patients care along
with the case manager to create a cost effective and efficient care plan for the patient
utilization review for monitoring and controlling cost of MCO correct answers assessing the
appropriateness of the services provided to the patients .
The utlization review process includes correct answers reviewing each patient's case to determine
the level of services appropriate , the setting the delivery of services will take place , determine
the most cost effective method ,and the need for followup/subsequent care
what are the two types of utilization review correct answers prospective and retrospective
prospective UR correct answers appropriateness of care is determined before the care is
delivered
retrospective UR correct answers managing services after care is already delivers by reviewing
medical records
practice profiling for monitoring and controlling cost of MCO correct answers used to decide
which providers have the right fit with the plans managed care philosophy and goals and is also
used to give feedback to providers so they can modify their own behavior of medical practice
, practice profiling with MCO correct answers is also know as profile monitoring , and is the
development of provider -specific practice patterns and comparisons of individual practice
patterns to some norm
MCO provider payment mechanisms include correct answers capitation, salaries, and discounted
fee
capitation correct answers is when the provider is paid a fixed monthly sum per enrollee, often
call per member per month payment PMPM
salaries correct answers is when the provider is paid , including bonuses or withholdings ,
provider=employee of MCO
discounted fee correct answers is when the provider is paid after the services have been delivered
to the patient . The provider can bill the MCo for each service separately but is paid according to
the pre-negotiated discount schedule (fee schedule)
what are the types of managed care organizations correct answers HMO, PPO, EPO, POS
what are the HMO types correct answers staff HMO, group HMO, network HMO, independent
practice association IPA
HMO stands for correct answers health maintenance organization
PPO stands for correct answers preferred provider organization
EPO stand for correct answers exclusive provider organization
POS stands for correct answers Point of service
what are the differing characteristics of managed care plans correct answers risk bearing ,
physician type, out of network coverage , relationship exclusivity
what 2 managed care plans have out of network coverage correct answers PPO and POS
what 2 managed care plans have exclusivity of relationship correct answers HMO STAFF and
HMO GROUP
what 2 managed care plans have large groups of physician types correct answers HMO GROUP
AND HMO NETWORK
what 3 managed care plans have physician risk bearing correct answers HMO GROUP, HMO
NETWORK , AND IPA
when did HMO enrollment gro rapidly correct answers first half of the 90's
