Ch. 3: Health Insurance

Question 1

HMO

Answer 1

health maintenance organization

Question 2

PPO

Answer 2

preferred provider organization

Question 3

EPO

Answer 3

exclusive provider organization

Question 4

IDS

Answer 4

integrated delivery system

Question 5

POS

Answer 5

point of service plan

Question 6

What are the 4 types of provider reimbursement methods?

Answer 6

1. salaried-providers are employed by the MCO
2. capitation-receive set fee per month per enrolled member, regardless of # of visits
3. fee-for-service-reimbursed for each service
4. negotiated or discount fee-same as fee for service, but providers agree to treat members for a reduced fee

Question 7

MCO

Answer 7

Managed care organizations-this is the five insurance models

Question 8

what are the 4 general types of HMOs?

Answer 8

1. staff model-the HMO operates and staffs the facility where members receive treatment
2. IPA-independent practice association-HMO contracts directly with physicians and hospitals
3. Group model-contracts with physicians who are organized as a partnership, corp, or association, HMO reimburses the group
4. network-contracts with more than one physician group

Question 9

How does a PPO work?

Answer 9

MCO contracts with a group of providers to offer services to the members. They are paid a maximum allowable fee, which is the most a PPO will pay for a given service, a discounted fee-for-service, or a capitation. Providers accept a reduced payment in return for high patient volume. Members are encouraged by receiving reduced co-payment by using the preferred providers, but it is up to them ultimately on who to use, as the non preferred providers will still be covered, just at a higher co-pay.

Question 10

How does an EPO work?

Answer 10

similar to a PPO except the members are restricted to use the participating providers for all health care services

Question 11

How does an IDS work?

Answer 11

it is an MCO that brings together physicians, p groups, hospitals, HMOs, PPOs, insurance companies, management services, and employers to integrate all aspects of patient care into one comprehensive system

Question 12

How does a POS work

Answer 12

usually, an HMO or PPO, that gives members a choice to receive services from providers outside of the MCO, members can self-refer to a specialist or other provider,

Question 13

assignment of benefits

Answer 13

permission granted by the insured that allows the insurance company to send payments directly to the provider

Question 14

preauthorization

Answer 14

determination of whether a specific service or treatment is medically necessary and covered by the insurance policy, required by many insurance companies

Question 15

precertification

Answer 15

determination of whether a specific treatment or service is covered by the policy

Question 16

predetermination

Answer 16

determination of the potential dollar amount the insurance company will pay for a specific treatment or service

Question 17

accept assignment

Answer 17

indicates that a physician or provider is willing to accept the amount the insurance company pays for a service as payment in full

Question 18

birthday rule

Answer 18

determines the primary payer for a child living with both parents and each parent carries health insurance. the primary payer is the parent whose birth month and date comes earlier in the calendar year

Question 19

coordination of benefits (COB)

Answer 19

applies when an individual is covered by more than one policy, ensures that the amount paid does need exceed the bill

Question 20

how does episode-of-care work?

Answer 20

charges a lump sum for all services associated with a particular problem, illness, condition, or procedure. Ex: surgical procedure (preoperative visits, surgery, postoperative)

Question 21

How does an HMO work?

Answer 21

Requires a PCP (primary care provider) to refer to specialist, have to stay in network, usually only requires a co-pay