Module 5 - Managed Care in the Medical Practice

Question 1

Provider Credentialing

Answer 1

Ensuring a provider meets certain standards (education, training, clinical judgement, character, etc.)

Question 2

Privileging

Answer 2

Determines a physicians Scope of Practice based on demonstrated competence

Question 3

What is Managed Care

Answer 3

Healthcare delivery system to manage healthcare cost, use and quality. (Insurance Companies)

Question 4

What does MCO stand for

Answer 4

MCO - Managed Care Organization

Question 5

NCQA

Answer 5

NCQA - National Committee for Quality Assurance

Question 6

JCAHO

Answer 6

JCAHO - Joint Commission on Accreditation of Healthcare Organizations

Question 7

AAHCC

Answer 7

AAHCC - American Accreditation HealthCare Commission

Question 8

MQC

Answer 8

MQC - Medical Quality Commission

Question 9

AAAHC

Answer 9

AAAHC - Accreditation Association for Ambulatory Healthcare

Question 10

Types of Managed Care is next

Question 11

Exclusive Managed Indemnity

Answer 11

Don’t have to have PCP
High Deductible Plan - Usually includes Prior Authorizations

Question 12

PHO - Physician Hospital Organization

Answer 12

Tied to a specific hospital - Providers own it and negotiate cost of hospital care

Question 13

PPO - Preferred Provider Organization - In Network

Answer 13

List of specific places/doctors that a patient can go for a low cost

Question 14

PPO - Preferred Provider Organization - Out of Network
aka
POS - Point of Service Plan

Answer 14

Large deductible and cost to the patient for services out of network.

Question 15

Silent PPO - Preferred Provider Organization

Answer 15

I don’t get it.

Question 16

HMO - Health Maintenance Organization

Answer 16

Medical practice agrees to provide certain services for a fixed amount of money. A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage.

Question 17

Capitation

Answer 17

The Health Maintenance Organization pays physicians a certain amount of money per patient, per month.

Question 18

Capitation Advantages

Answer 18

1. Predictable Cash Flow
2. Patient Growth with Referrals
3. Decreased paperwork related to claims

Question 19

Capitation Disadvantages

Answer 19

1. Possible portion of revenue lost due to withhold tied to plan performance
2. Possible loss of revenue due to services included in capitation

Question 20

How does the MCO ‘s Contract relate to Medical Necessity

Answer 20

If a service is not stated clearly in the contract the medical necessity can be negotiated

Question 21

Risk Pools and Bonuses

Answer 21

Money withheld from Capitation Payments to cover emergent excess expenses.

Question 22

Payer Reinsurance

Answer 22

Purchased by primary insurers to protect against excessive claim losses.

Question 23

What’s a Birthday Rule in a Managed Care Contract (Insurance Plan)?

Answer 23

For children. If both parents have insurance, the child is insured by the parent whose birthday comes first in the calendar year.
This is not law and plans don’t have to follow the rule.

Question 24

Physician Participation in relation to Physician Utilization Committee

Answer 24

A Committee of Physicians who discuss:

Planned referrals to specialists
Alternatives to care to achieve same outcome
Work done by colleagues to solve other healthcare problems