key common characteristics of ppos do not include

-overseeing and maintaining final responsibility for the plan. In the United States, we have a private and competitive health insurance system which will cause managed care to continue to evolve. Category: HSM 546HSM 546 PPOs feature a network of health care providers to provide you with healthcare services. A- Occupancy rate 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. C- Independent Physician Association model What is the best managed care organization? Scope of services. True or False 7. Part B (Medical Insurance) covers most medically necessary doctors' services, preventive care, durable medical equipment, hospital outpatient services, laboratory tests, x-rays, mental health care, and some home health and ambulance services. Key common characteristics of PPOs include: Prepayment for services on a fixed, per member per month basis. C- Mission clarity false commonly, recognized types of hmos include all but Phos Most ancillary services are broadly divided into the following two categories. 3. HMOs are licensed as health insurance companies. B- New federal and state laws and regulations, T/F The function of the board is governance: the managed care backlash resulted in which of the following: B- Reduction in drug interactions and resulting serious adverse effects . when either the insured or the insurer knows something that the other one doesn't. Negotiated payment rates. What technique is used by many pharmaceutical companies with health plans and PBMs to increase formulary access and utilization of specific products? What is the common benefit design trend in commercial (employer group sponsored) prescription drug benefits? ), the original impetus of HMOs development came from: Point of Service (POS): A POS managed care plan is offered an option within many HMO plans. B- Cost of services B. 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. HIPDB = healthcare integrity and protection data bank, T/F Orlando and Mary lived together for 14 years in Wichita, Kansas. 4. Oilwell_______b.Trademark_______c.Leasehold_______d.Goldmine_______e.Building_______f.Copyright_______g.Franchise_______h.Timberland_______i. Blue Cross began as a physician service bureau in the 1930s. Employers are usually able to obtain more favorable pricing than individuals can (POS= point of service), which organization may conduct primary verification of a physician's credentials? Some. the affordable care act requires US citizens to: -broader physician choice for members *ALL OF THE ABOVE*. C- Having medical school professors present detailed studies at CME conferences *Federal legislation that superseded state laws that restricted the development of HMS. Money that a member must pay before the plan begins to pay . key common characteristics of ppos do not include The activity of PPO decreased slowly after heat pretreatment for 5 min. A- Inpatient DRGs Step-down units Which of the following is a typical complaint providers have about health plan provider profiling? key common characteristics of PPOs include: -selected provider panels You can use doctors, hospitals, and providers outside of the network for an additional cost. PPOs feature a network of health care providers to provide you with healthcare services. PPOs generally offer a wider choice of providers than HMOs. D- A & B only, D- A and B (POS plans and HMOs) TF Health insurers and Blue Cross Blue Shield plans can act as third party administrators (TPAs). Key common characteristics of PPOs include: Selected provider panels Negotiated payment rates Consumer choice & Utilization management EPOs share similarities with: PPOs and HMOs Commonly recognized HMOs include: IPAs Capitation is usually defined as: Prepayment for services on a fixed, per member per month basis PPOs tend to have higher monthly premiums in exchange for the flexibility to use providers both in and out of network without a referral. *Prepayment for health care Different types of major medical health insurance include: Obamacare health insurance plans for individuals and families. Almost all models of HMOs contract directly with physicians. 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. 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. B- Staff model The term "managed care" is used to describe a type of health care focused on helping to reduce costs, while keeping quality of care high. D- All the above, Which organization(s) need a Corporate Compliance Officer (CCO)? 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. UM focuses on telling doctors and hospitals what to do. False. 2.1. What patterns do you see? Copayment is: a. A- Broader physician choice for members physicians avoid working for hospitals as much as possible, utilization management seeks to reduce practice variation while promoting good outcomes and: 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. Salt mine}\\ This may include very specific types . B- Insurance companies Ancillary services are broadly divided into the following categories: One potential negative consequence of drug formularies with high copayments is: High copayments may be a barrier to adherence. Two cash effects can be netted and presented as one item in the investing activities section. B- My patients are sicker than other providers' patients The amount of resources a country allocates for healthcare varies based on its political, economic, and social characteristics. D- Medicare Part D, Approximately 50% of behavioral care spending is associated with what percentage of patients? Plans that restrict your choices usually cost you less. Coinsurance is: a. A- Validity What specific factors other than diseases commonly affect severity of illness? HMO. A- Providers seeking patient revenues Ammonia Reacts With Oxygen To Produce Nitrogen And Water, The most common health plans available today often include features of managed care. A high-level tyoe of indemnity insurance that applies only to high-cost cases or higher than predicted overall costs. Closed-Panel HMOs. An IDS can be described as a legal entity consisting of more than one type of provider to manage a populations health care and/or contract with a payer organization. Orlando currently lives in California. Key common characteristics of PPOs include: Selected provider panels Negotiated provider payment rates Consumer choice Utilization management. *enrollees who are willing to pay higher cost sharing may access providers that are not in the contracted network Out-of-pocket medical costs can also run higher with a PPO plan. which of the following is not a provision of the Affordable Care Act? PPO (Preferred Provider Organization) PPO plans are among the most common types of health insurance plans. What is the effective interest rate per quarter if the interest rate is 6%6\%6% compounded continuously? What is the funding source of each program? C- State Medicaid programs General oversight of the profitability or reserve status rests with the board, as does oversight and approval of significant fiscal events and quality management. Question 1.1. Members . Medicaid D- All the above, D- all of the above The characteristics of a medical expense or indemnity health insurance plan include deductibles, coinsurance requirements, stop-loss limits and maximum lifetime benefits. 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. D- Network model, the integral components of managed care are: peer pressure works through "shaming" physicians into changing behavior, Behavioral change tools include all but which of the following? Health Maintenance Organization - HMO: A health maintenance organization (HMO) is an organization that provides health coverage for a monthly or annual fee. which of the following are considered the forerunner of what we now call health maintenance organizations? They do not apply to self-funded benefits plans, Medicare or (usually) Medicaid. B- Pharmacy and radiology Marketing Essentials: The Deca Connection, Carl A. Woloszyk, Grady Kimbrell, Lois Schneider Farese. In order to verify that the filler is set up correctly, the company wishes to see whether the mean bottle fill, \mu, is close to the target fill of 161616 ounces. Benefits determinations for appeals Fastest Linebacker 40 Time, For both PPO and HMO plans, your costs for care will be lowest if you receive it from in-network providers. D. Utilization . In what model does an HMO contract with more than one group practice provide medical services to its members? One particular souvenir is the football program for each game. New federal and state laws and regulations. Board of Directors has final responsibility for all aspects of an independent HMO. Compared to PPOs, HMOs cost less. A PHO is usually a separate business entity requiring the participation of a hospital and at least some of the hospitals admitting physicians. State and federal regulations consistently apply network access standards to: Which of the following organizations may conduct primary verification of a physician's credentials? was the first HMO. A reduction in HMO membership and new federal and state regulations. A- Point-of-service programs D- Inpatient setting, establishing a high level of evidence regarding disease management guidelines ensures: Payment: If the primary care doctor makes a referral outside of the network of providers, the plan pays all or most of the bill. Statutory capital is best understood as. An IPA is an HMO that contracts directly with physicians and hospitals. T/F A- Diagnostic and therapeutic Key common characteristics of PPOs do not include : a . the same methodology used to pay a hospital for in patient care is also used to pay for outpatient care, T/F _______a. Commonly recognized HMOs include: IPAs. d. Not a type of cost-sharing. 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? True or False 10. Both overfilling and underfilling bottles are undesirable: Underfilling leads to customer complaints and overfilling costs the company considerable money. A- The Department of Defense TRICOR program Key Takeaways 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). \text{\_\_\_\_\_\_\_ b. Prior to the 1970s, health maintenance organizations (HMOs) were known as: The majority of prescriptions for behavioral health medications are written by nonpsychiatrists. healthcare cost inflation is attributed to: the HMO act included which of the following features: it made federal grants and loan grantees available for planning, starting, and/or expanding HMOs, more than 1900 mergers and acquisitions of hospitals occurred during the 1990's, in a point of service (POS) plan, members have HMO-like coverage with little or no cost sharing if they both used the HMO network and access care through their PCP, the ACA authorized the creation of accountable are organizations (ACOs). managed care plans perform onsite reviews of hospitals and ambulatory surgical centers, T/F D- A & B only, T/F Coverage limitations, A fixed amount of money that may be put towards a benefit. Selected provider panels C- Laboratory tests 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. board of directors has final responsibility for all aspects of an independent HMO. True. C- Short Stay clinic C- Reduction in prescribing and dispensing errors True. T/F Risk-bering PPos consolidation in the payer industry has resulted in most hospitals being unable to obtain adequate rate increases, false A- Improvement in physician drug formulary prescribing conformance Increasing copayment amounts, especially for Tier 2 preferred brand drugs and Tier 3 non-preferred brand drugs. HSM 546 W1 DQ2 ManagedCare Plans quantity. Which set of postoperative PPOs was used did not inu-ence the surgical procedure in any way. 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. How are outlier cases determined by a hospital? Every home football game for the past 8 years at Southwestern University has been sold out. -utilization management Concepts of Managed Care MIDTERM HA95.docx, Test Bank Exam 1 Principles of Managed Care 012820.docx, Your formal report will explore these issues in your major course of study/industry and will require that you recommend solutions to address the problem/issue (recommendation report). Pay for performance (P4P) cannot be applied to behavioral health care providers. -consumer choice Some of the key differences include the quality of care, payment for care and the way enrollees choose physicians. a. D- none of the above, common sources of information that trigger DM include: 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 alton herald obituaries, will madden 23 be cross platform, false depth chalice dungeons,

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