Insurance7

Question 1

Features of HMOs

Answer 1

Managed care
■ Prepaid services
■ Co-pays
■ Gatekeeper (Primary Care Physician)
■ Limited choice of providers
■ Limited service area

Question 2

Preferred Provider Organization

Answer 2

Managed care
■ Fee for service
■ Pre-negotiated rates
■ Insured pays less in network of PPO providers

Question 3

Point of Service

Answer 3

HMO allows subscribers to use providers outside of the HMO
■ No gate keeper for out of network services
■ Subscribers pay more of the cost
■ Called open-ended HMO

Question 4

Cost Containment—Managed Care

Answer 4

Preventive Care
■ Reducing Hospital Care Costs
–– Outpatient Benefits
■ Second Surgical Opinion
■ Preauthorization—precertification
■ Limits on Lengths of Stay
■ Alternatives to Hospital Care
–– Skilled nursing facilities
–– Intermediate nursing facilities
–– Rehabilitative facilities
–– Home health care
■ Utilization Management
–– Prospective review
–– Concurrent review
–– Retrospective review