Provider Networks Flashcards
1
Q
Provider Network
Administrator Considerations to Manage Provider Network
A
- Goal of network
- Comply with regulations
- Meet quality standards
- Manage cost
- Manage risk
- Ongoing evaluation of network
2
Q
Provider Network
Administrator Network Goals
A
- Financial stability/growth
- Specific population needs
- Preserve market share/Negotiation leverage
3
Q
Provider Network
Employer Network Goals
A
- Legal requirement (for many)
- Important part of total compensation package
4
Q
Provider Network
Consumer Network Goals
A
- Cost of Plan
- Provider Composition
- Brand Loyalty
- Existing relationship with physician
- Proximity of providers
- Network reputation
- Expectations of Plan/Network
- Timely paid claim
- Clear/quick responses to questions
- No unreasonable delays in care
- No surprise billing
5
Q
Provider Network
Provider Network Goals
A
- Earn fair, predictable source of income
- Spend as little time as possible on admin functions
6
Q
Provider Network
Purpose of Model Law
A
Ensure network has:
- Adequacy
- Accessibility
- Transparency
- Quality of service
7
Q
Provider Network
Primary Domains of Network Adequacy
A
- Provider Composition
- Geographical Access
- Consumer Protection
- No balance billing
- Hold Harmless agreement
8
Q
Provider Network
Steps in Establishing and Using Quality Measures for Providers
A
- Establish validity of quality measures
- Assign measure to domain
- Determine algorithm to determine if quality measure is met
9
Q
Provider Network
Quality Measures (Types)
A
- Structural (Qualifications, Staffing)
- Process (Admin of care, Adherence to evidence-based medicine rules)
- Outcome (End effects of care)
10
Q
Provider Network
Levers to Help Control Costs
A
- Limiting benefits not deemed medically necessary
- Dx management
- UM
- Encouraging provider efficiency
- Reimbursement methodology
11
Q
Provider Network
Provider Efficiency Measurement Methods
A
- Portfolio = Compare eff. for provider to market average
- Total Cost of Care = Use risk-adjusted data to compare costs of members
12
Q
Provider Network
Provider Reimbursement Methods
A
- FFS
- FFS w/ Link to Quality and Value
- Alternative Payment Method built on FFS Architecture
- Population-Based Reimbursement
13
Q
Provider Network
Key Decisions for Administrator in Setting Up Capitation Arrangement
A
- Member attribution (PCP)
- Structure of capitated services (flat dollar or risk-adjusted)
- How much risk admin is willing to take on for non-cap services
14
Q
Provider Network
Disruptors in Network Risk Management
A
- Legislative changes
- Pandemics
- Economic Conditions
- Competition
