1.8 Cost Containment Principles

Question 1

Traditional insurance uses cost containment strategies in the form of?
1.
2.
3.

Answer 1

1. Coinsurance
2. Co-payments
3. deductibles

Question 2

Is a set amount the patient pays each time a specific service is rendered.

Answer 2

co-payment

Question 3

is a specific amount of money the patient must pay for covered expenses before the insurance company begins paying.

Answer 3

Deductible

Question 4

There are 2 main types of managed care organizations.
1.
2.

Answer 4

1. Preferred Provider Organizations (PPOs)

2. Health Maintenance Organizations (HMOs)

Question 5

This type of managed care organization contains cost by negotiating discounts for services with providers as a condition for being included in this type of managed care.

Answer 5

Preferred Provider Organizations (PPOs)

Question 6

This type of managed care organization provides healthcare services to members for a set yearly fee per member. (often use PCPs as gatekeepers and emphasize preventative care)

Answer 6

Health Maintenance Organizations (HMOs)

Question 7

Medicare implemented the ___ ____ ____ system, in which a fixed amount is payed for a given diagnosis, rather than paying all costs related to an individual patient’s treatment during his or her hospital stay.

Answer 7

Diganosis Related Group (DRG)

Question 8

Is a system of healthcare delivery whose goal is to maintain quality, cost-efficient care by managing the use, access, cost, quality, and effectiveness of services.

Answer 8

Managed Care

Question 9

PPOs contract with providers to deliver care at a discounted rate. The providers with whom they contract are considered “_____ ______.”

Answer 9

network providers

Question 10

This organization is similar to a PPO in that a network of providers have agreed to provide care for the members at a discounted rate. In this organization, however, a patient is not reimbursed for services if he chooses to receive healthcare outside of the network.

Answer 10

Exclusive Provider Organization (EPO)

Question 11

This plan is a combination of PPO and HMO. The patient can choose to receive care at in-network at little or no cost, or to go out-of-network and incur larger out-of-pocket expenses.

Answer 11

Point-of-Service

Question 12

Services that are not included in the contract between the provider and the HMO can be “___ ___” services.

Answer 12

carve out

Question 13

HMOs often use PCPs as what?

Answer 13

Gatekeepers

Question 14

4 types of HMOs:
1
2
3
4

Answer 14

1. Group Model HMO
2. Network Model HMO
3. Individual Practice Association (IPA) Model HMO
4. Staff Model HMO

Question 15

this model HMO contracts with a multi-specialty physician group, where the physicians are employed by the group, not the HMO

Answer 15

Group Model HMO

Question 16

this model HMO is similar to the group model but involves more than one group of physicians.

Answer 16

Network Model HMO

Question 17

This HMO model contracts with physicians who provide healthcare to the HMO members for a negotiated rate. They own there own practices.

Answer 17

Individual Practice Association HMO model

Question 18

In this HMO model physicians are employed by the HMO and provide services exclusively to members of the HMO.

Answer 18

Staff Model HMO