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The process that Mr. Sybex used to identify and classify the risk represented by the Koster Group so that Intuitive can charge premiums that are adequate to cover its expected costs is known as
The following statements describe common types of physician/hospital integrated models:
The Iota Company, which is owned by a group of investors, is a for-profit legal entity that buys entire physician practices, not just the tangible assets of the practice
System classifies hundreds of hospital services based on a number of criteria, such as primary and secondary diagnosis, surgical procedures, age, gender, and the presence of complications.
Specialty services that have certain characteristics generally are good candidates for managed care approaches. These characteristics generally include that the specialty service should have
Many of the credentialing standards and criteria used by health plans are often taken from already existing standards established by
Khalyn Drury's employer includes managed dental care in its employee benefits package. During open enrollment, Ms. Drury enrolled in the dental plan, which provides dental services to its members in exchange for a prepayment (the premium). Dental services
Parable Healthcare Providers, a health plan, recently segmented the market for a new healthcare service. Parable began the process by dividing the healthcare market into two broad categories: non-group and group. Next, Parable further segmented the non-gr
Individuals can use HSAs to pay for the following types of health coverage:.
Parul Gupta has been covered by a group health plan for eighteen months. For the past four months, she has been undergoing treatment for diabetes. Last week, Ms. Gupta began a new job and immediately enrolled in her new company's group health plan, which
Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the
In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:
HMOs typically employ several techniques to manage provider utilization and member utilization of medical services. One technique that an HMO uses to manage member utilization is
Federal Employee Health Benefits Program (FEHBP) requires health plans offering services to federal employees and their dependents to provide
A particular health plan offers a higher level of benefits for services provided in-network than for out-of-network services. This health plan requires preauthorization for certain medical services.
With regard to the steps that the health plan's claims e
Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health pl
Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for:
The following statements are about the various Health Plan Accountability Models adopted by the NAIC.
Natalie Chan is a member of the Ultra Health Plan. Whenever she needs non-emergency medical care, she sees Dr. David Craig, an internist. Ms. Chan cannot self-refer to a specialist, so she saw Dr. Craig when she experienced headaches. Dr. Craig referred h
One of the distinguishing characteristics of healthcare marketing is that many of the markets for health plans are national, not local markets.
One type of physician-only integration model is a consolidated medical group. Typical characteristics of a consolidated medical group include
The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be
The Cleopatra Group, a third-party administrator (TPA), has entered into a TPA agreement with the Alexander MCO with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. On
Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves
One ethical principle in managed care is the principle of justice/equity, which specifically holds that MCOs and their providers have a duty to
The Blaine Healthcare Corporation seeks to manage its quality by first identifying the best practices and best outcomes for a given procedure. Blaine can then determine areas in which it can emulate the best practices in order to equal or surpass the best
Janet Riva is covered by a indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan. She incurred
The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential
When the Knoll Company purchased group health coverage from the Castle Health Maintenance Organization (HMO), the agreement between the two parties specified that the plan would be a typical fully funded plan. Because Knoll had been covered under a previo
Which facility would best meet the need of Jack who fell on road and sprained his ankle?
The nature of the claims function within health plans varies by type of plan and by the compensation arrangement that the plan has made with its providers. For example, it is generally correct to say that, in a
Consolidation of patient information in a single location as can be used by independent providers is an example of
The measures used to evaluate healthcare quality are generally divided into three categories: process, structure, and outcomes. An example of a process measure that can be used to evaluate a health plan's performance is the:
The process of identifying and classifying the risk represented by an individual or group is called
The statements below describe technology used by two health plans to respond to incoming telephone calls:
In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known
During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, fo
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
For providers, integration occurs when two or more previously separate providers combine under common ownership or control, or when two or more providers combine business operations that they previously carried out separately and independently. Such provi
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
In order to cover some of the gap between FFS Medicare coverage and the actual cost of services, beneficiaries often rely on Medicare supplements. Which of the following statements about Medicare supplements is correct?
Using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider is called ______________.
If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info
As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members:
Greentree Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area. Abigail Davis, a recruiter for Greentree, has been meeting with Melissa Cortelyou, M.D., in an effort to recruit her as a PCP in Green
In assessing the potential degree of risk represented by a proposed insured, a health underwriter considers the factor of anti selection. Anti selection can correctly be defined as the
A health savings account must be coupled with an HDHP that meets federal requirements for minimum deductible and maximum out-of-pocket expenses. Dollar amounts are indexed annually for inflation. For 2006, the annual deductible for self-only coverage must
TESTED 29 Apr 2024