question

Indemnity insurance

answer

Insurance that "indemnifies" the policy holder from losses. In health insurance, this applies to providing financial coverage for health care costs, with little or no attempt to manage that cost; most important, it is not based on a contracted network of providers, unlike a service plan that may otherwise appear the same.

question

carve outs

answer

refers to a set of medical services that are "carved out" of the basic arrangement.

question

providers

answer

generic term used to refer to anyone providing medical services. In fact, it may even be used to refer to anything that provides medical services, such as a hospital.

question

(ERISA) Employee Retirement Income Security Act

answer

-One provision of this act allows self-funded plans to avoid paying premium taxes, avoid complying with state-mandated benefits, and generally avoid complying with state laws and regulations regarding insurance, even when insurance companies and managed care plans that stand risk for medical costs must do so. -another provision requires that plans and insurance companies provide an explanation of benefits (EOB) statement to a member or covered insured in the event of a denial of a claim, explaining why the claim was denied and informing the individual of his or her rights of appeal.

question

Balanced Budget Act of 1997

answer

-provided for the creation of PSOs to provide a vehicle that would allow providers to contract directly with Medicare to accept risk for services and costs to an enrolled group of Medicare beneficiaries -act required the PSO to provide a substantial portion of health care directly or through affiliated groups of providers and for the providers themselves to have at least a majority ownership interest in the PSO.

question

(MMA) Medicare Modernization Act

answer

-new forms of managed care-Medicare Advantage - Managed care for Medicaid programs in the states -More emphasis on chronic and highly expensive medical conditions with less focus on routine care

question

Genomics

answer

-in the area of this, the appearance of so-called specialty pharmacy, injectable drugs that are proteins manufactured through DNA replication, has led to treatments that may not be used frequently but that are hugely expensive when they are, commonly costing in excess of $10,000 per patient per year

question

(HIPAA) Health insurance portability and accountability act

answer

-Enacted in 1997, this act creates a rather vaguely worded set of requirements that allow for insurance portability, guaranteed issue of all health insurance products to small groups, and mental health parity. -also contains significant provisions regarding "administrative simplification" and standards for privacy and security -Improved basic transactions in managed care including: claims, claims status, authorizations, eligibility checking, payment -privacy of medical records -security & electronic transactions

question

(HEDIS) Healthcare Effectiveness Data and Information Set

answer

-developed by NCQA w/ considerable input from the employer community and the managed care community, is an ever-evolving set of data reporting standards.

question

(PPO) Preferred Provider Organization

answer

A plan that contracts with independent providers at a discount for services

question

(POS) Point of Service

answer

A plan in which members do not have to choose how to receive services until they need them

question

(IPA) Independent Practice Association

answer

An org. that has a contract with a managed care plan to deliver services in return for a single capitation rate.

question

(COA) Certificate of Authority

answer

the license required by an HMO or MCO that is issued by a state after the HMO meets regulatory requirements. A form of state licensure

question

(EPO) Exclusive Provider Organization

answer

-is similar to an HMO in that it often uses primary physicians as gatekeepers, often capitates providers, has a limited provider panel, uses an authorization system, and so forth.

question

(PMPM) Per member per month

answer

Specifically applies to a revenue or cost for each enrolled member

question

(PSRO) Professional Standards Review Organization

answer

-In 1972, Social Security Amendment authorized this -Review appropriateness of care provided to Medicare/Medicaid beneficiaries -Organizations effectiveness is debated -Large corporations initiated pre certification, concurrent review for inpatient cases -Promoted employee wellness -Members of large corporations were sitting on hospital boards to constrain costs, negotiate payment levels directly to providers

question

(PSO) Provider-sponsored organization

answer

-entity allowed under the BBA 97' Medicare + Choice. -risk-bearing managed care org. that contracts directly w/ CMS for Medicare enrollees -unlike HMO, PSO is made up of the providers themselves, and the providers bear substantial risk for expenses

question

(CDHP) Consumer-directed health plan

answer

-type of health plan that combines a high-deductible health insurance policy with a pretax fund such as an HSA or HRA -they are used to pay for qualified services on a first-dollar basis but is not large enough to cover the entire deductible, so called doughnut-hole -CDHPs also provide info such as cost data and decision support tools to consumers to promote greater involvement on the part of the consumer in making health care choices (HSA, greater cost sharing for consumers with accountability and choice, pre-tax funds, improved info to the consumers)

question

(HSA) Health Savings Accounts

answer

-created under the MMA, is a financial account of pretax dollars for current or future qualified medical expenses, retirement, or long-term care premium expenses

question

(RVFS) Relative Value Fee Scale

answer

...

question

Tax Equity and Fiscal Responsibility Act (TEFRA)

answer

-authorized the Medicare program to pay HMO's on a captivated basis provided that they met Medicare's participation requirements -the intent was to control health care costs and more comprehensive benefits -HMO's offered lower amounts of cost sharing, prescription costs, and preventive services

question

Characteristics of a managed care organization:

answer

written contract, prepaid, usually has a utilization review ??

question

How does the MCO work?

answer

have to 1st subscribe to it, then choose PCP, PCP notifies that DR and let them know coming, then get authorization ??

question

During the pre-WWII era, name the 2 models that existed for prepaid health care?

answer

-HMOs (prepaid, not covered until 1970) -Blue Cross Blue Shield

question

Father of the Health Management Organization:

answer

Dr. Paul Ellwood

question

What impact did the HMO act have on the growth of the managed care industry? Name the characteristics.

answer

-made grants & loans available for the planning and start-up phases of new HMOs as well as for service area expansions for existing HMOs -overrode state laws that restricted the development of HMOs if the HMOs met federal requirements for certification -required employers with 25 or more ees that offered indemnity coverage also to offer up to 2 different types of federally qualified HMO options if the plans made a formal request

question

Why was the managed care industry so slow to grow until the late 1980s and 1990s?

answer

opposition by federal group, state was restrictive ?

question

In 1972, the Social Security Amendment authorized the professional standard review organization, what was its purpose?

answer

to review appropriateness of care provided to Medicare and Medicaid beneficiaries in hospitals -established an organizational infrastructure and data capacity on which both the public and private sectors could rely -replaced by the Peer Review Org. (PRO), itself replaced by the quality improvement org. (QIO) -concurrent review (1970s) for inpatient care, why still happening today

question

What developments of indemnity insurance in the 1980s brought changes in the insurance industry?

answer

-encouraging persons with conventional insurance to obtain 2nd opinions before undergoing elective surgery -adopting "large case management" (the coordination of services for persons with conditions that require expensive medical care, such as selected accident patients, cancer patients, and very low birth weight infants)

question

In 1991, the National Committee on Quality Assurance (NCQA) began to accredit HMO's, what function did it serve?

answer

-initially focused only on HMOs, has evolved with the market -performance measurement systems (report cards) continue to evolve, the most prominent being the Health Care Effectiveness Data and Information Set (HEDIS) which was developed by NCQA -another form of maturation is the focus of cost management efforts, which used to be almost exclusively inpatient hospital utilization -credential in a proper manner

question

In 2007, only 4 major commercial for profit insurance companies accounted for 45% of the covered individuals: Name them:

answer

CIGNA, Aetna, United Health Care, and Wellpoint

question

What impact did Utilization Management have on the managed care industry?

answer

-Shortened LOS, -Mandating managed care systems-DRGs -Utilization Review ?

question

What were the mitigating circumstances that caused the backlash of negative publicity and anti-managed care sentiment?

answer

-lack of choice -mistakes in paperwork or claims processing -denial of care not medically necessary -prior authorization from PCP to access speciality care -denial of coverage for necessary medical care -accusation that health plans deliberately refused to pay for necessary care to generate profits -America's desire for choice

question

What has impacted the inflation of health costs in the last decade?

answer

-increase number of outpatient procedures -higher admin costs -drug therapy advances -consumer demands -high rate of lawsuits -aging of pop. -expectations of long healthy life -cost of complying with govt mandates -rapidly advancing medical technology -genomics

question

Name the advantages and disadvantages of the managed care system?

answer

-Advantages: -gave us quality of care w/ emphasis by broadening quality measurements and mgmt beyond the hospital setting -standard measurements for quality on HEDIS -advancement from inpatient to outpatient -contributed to policy makers & large employers being comfy with contracting with MCOs/HMOs -public distress led to standard measures such as HEDIS -Disadvantages: -MCO focused on cost vs. care -did not make sufficient efforts to self regulate -did not respond to backlash, viewed it as a public relations problem -opposed sensible regulation -vast amounts of wealth

question

Name the 3 broad types of risk agencies

answer

-govt programs -insurance -self funded programs

question

What are the components of the risk agencies: govt program?

answer

-Medicare (elderly & disabled, CMS), Medicaid (poor), Military programs, Tricare (under the Civilian Health and Medical Program of the Uniformed Services), Veterans Administration, Indian affairs

question

What are the components of the risk agencies: Insurance?

answer

Group Health Benefits, Wraparound or Supplemental health insurance, individual health insurance

question

What are the components of the risk agencies: self funded health benefits plan?

answer

-regulated by ERISA -Employer assumes the risk of medical costs -attractive to large companies -Advantages: no premium tax, no mandated benefits, costs alone determine costs, and less regulated -Use of third party administrator (TPA) -Use of reinsurance to protect against catastrophic loss

question

Define an entitlement program

answer

certain individuals to receive benefits from the government. Risks for medical expenses are borne by the state/federal agencies and tax payers

question

Medicare program

answer

Centers for Medicare and Medicaid Services (CMS) a branch of the U.S. Dept. of Health and Human Services -services for the elderly -individuals w/ end stage renal disease

question

Medicaid program

answer

Managed by the state which receive state and federal funds -provide health insurance to the poor, disabled, and institutionalized individuals

question

What is the Federal Employees Health Benefit Program? (FEHBP)

answer

-Acts as an employer -Makes health insurance plans (MCOs) available to federal employees -Federal government is acting like any other employer -Known as an employer-based Health group benefits plan

question

Characteristics of a basic insurance plan:

answer

bears the risk for medical expenses, risk for medical expenses belongs to the insurer (copayments, coinsurance), regulation of this industry is the responsibility of the state govts except for HIPAA (insure themselves against catastrophic costs)

question

What is a group health benefit plan and how does it function?

answer

Advantages: insurance paid pretax, more favorable pricing than individual, combine with other benefits employer administers -Defined contribution-employer provides employees a fixed amount of money (disadvantages for employees)

question

What are the advantages of a group benefit plan?

answer

-cost of insurance is paid on a pretax basis -employers obtain favorable pricing and coverage than individuals -employer manages administrative needs such as payroll, payment of premiums -health insurance cane be combined with other benefits (life insurance, dental)

question

What is a wrap around/ Supplemental insurance?

answer

-an insurance policy that covers what another insurance policy or Medicare does not cover -a wraparound would provide the missing coverage, subject to the limitations -most common are sold to Medicare beneficiaries

question

Explain Self Funded Health Benefit Plans:

answer

-regulated by ERISA -employer assumes the risk of medical costs -attractive to large companies -Advantages: no premium tax, no mandated benefits, costs alone determine costs, and less regulated -use of third party administrator (TPA) -use of reinsurance to protect against catastrophic loss

question

Define Traditional Indemnity Health Insurance

answer

-Indemnity-protects the patient against financial losses from medical expenses -no restrictions on providers for medical care -precertification for elective admissions -2nd opinions may be mandated -subscriber must pay a deductible before insurance pays -very expensive compared to managed care plans -case mgmt for catastrophic cases -any charges by provider that insurance company does not pay are responsibility of patient

question

What is a consumer directed health plan?

answer

-combine a HDHP (high deductible) with a pretax fund such as an HSA or HRA -the HSA or HRA are used to pay for qualified services on a first dollar basis, but are not large enough to cover the entire deductible (donut hole) -CDHP also provides info such as cost data and decision support tools to consumers to promote greater involvement on the part of the consumer in making health care decisions -HSA's were created by the MMA -Both HSA's and HRA's are regulated by the U.S. Treasury Dept. -CDHPs are not considered managed health care plans, but similar to indemnity insurance plans of the past -Most are associated with a PPO -Consumers do not know the real health care costs so this adds extra padding for the bill

question

Explain the 2 basic forms of CDHP?

answer

-Employer based using a health payment account (HRA)-Health risk appraisal, an instrument to compile data -Individual based using health savings account (HSA)-financial account of pretax dollars

question

(PPO) Preferred Provider Organization

answer

-are organizations that provide discounted provider services to insurance carriers and employers -discounts are greater -pre certification -if the subscriber wishes to seek care from a non-participating provider, the responsibility falls on the subscriber, and at risk for charges (80% vs. 60%) -less expensive than regular insurance

question

(POS) Point of Service

answer

-a plan in which members do not have to choose how to receive services until they need them -most common use of the term applies to a plan that enrolls each member in both an HMO system and a PPO or an indemnity plan -these plans provide a difference in benefits depending on whether the member chooses to use the plan or go outside the plan for services -Primary care physician acts as the gatekeeper for referrals

question

Open Access HMO

answer

-a term that refers to an HMO that does not use a primary care physician gatekeeper model for access to specialty physicians -a member may self-refer to a specialty physician rather than seeking authorization from the PCP -more like traditional PPO's than traditional HMO's -members may access any provider in the HMO w/o going through PCP

question

Open Panel

answer

-a managed care plan that contracts w/ private physicians to deliver care in their own offices -private physicians and other professional providers -independent contractors who see HMO members in their own offices -may contract w/ more than 1 health plan and see fee-for-service patients -number of pts in the open plan in larger than the closed plan -member must choose a PCP to authorize services

question

Closed Panel

answer

-a managed care plan that contracts with physicians on an exclusive basis for services and does not allow those physicians to see patients for another managed care organization. -Examples include staff and group model HMOs. -It could apply to a large private medical group that contracts with an HMO

question

Group Model

answer

-HMO contracts with a group of physicians to provide services to HMO members -physicians are employed by the practice -the group pays the individual physicians through a combination of salary and risk/reward incentives -the group is at risk if the cost exceeds the captivated amount, the reimbursement is less -also serve non-HMO patients -best example: Kaiser Permanente

question

Staff Model

answer

-an HMO that employs providers directly, and those providers see members in the HMO's own facilities - a form of closed panel HMO -physicians are working for a large corp., and the legal issues are reduced -physicians are paid a salary

question

Balance Billing

answer

the practice of a provider billing a patient for all charges not paid for by the insurance plan, even if those charges are about the plan's UCR or are considered medically unnecessary

question

Service Plans

answer

-a health insurance plan that has direct contracts with providers but is not necessarily a managed care plan

question

(IPA) Independent Practice Association

answer

an organization that has a contract with a managed care plan to deliver services in return for a single capitation rate -the IPA in turn contracts with individual providers to provide the serves either on a capitation basis or on a fee-for-service basis -typical IPA encompasses all specialties, but an IPA can be solely for primary care or may be single specialty

question

(PHO) Physician-Hospital Organization

answer

-legal (informal) organizations that bond hospitals and the attending medical staff and were developed for the purpose of contracting with managed care plans -may be open to any members of the staff who apply, or they may be closed to staff members who fail to qualify

question

(MSO) Managed Service Organization

answer

-form of integrated health delivery system -often actually purchases certain hard assets of a physician's practice and then provides services to that physician at fair market rates -are usually formed as a means to contract more effectively with managed care organizations, although their simple creation does not guarantee success

question

(PSO) Provider-Sponsored Organization

answer

Cooperative venture of a group of providers who control financial arrangements and health service delivery and activity that is focused on the Medicare community

question

(PPMC) Physician practice mgmt company

answer

-are for physicians only not hospitals -manages all support functions, but not the clinical aspects of the physician's practices -usually takes a % of the practice revenue -takes a long term commitment and agrees not to compete with other physicians if he leaves the company -has had many failures

question

(EPO) Exclusive Provider Organization

answer

-is similar to an HMO in that is often uses primary physicians as gatekeepers, often capitates providers, has a limited provider panel, uses an authorization system, -referred to as exclusive because the member must remain within the network to receive benefits -are generally regulated under insurance statutes rather than HMO regulations

question

(GPWW) Group practice without walls

answer

-a group practice in which the members of the group come together legally but continue to practice in private offices scattered throughout the service area -independent of hospitals -physician's productivity is the most important factor in determining his or her income while part of a medical group

question

Foundation Model

answer

IDS model: -formed when a hospital creates a not for profit foundation and purchases physicians' practice, then places them in the foundation -formed when a legal reason prevents a hospital from employing physicians directly or using hospital funds to purchase physician practices -governed by boards not dominated by either the hospital or physicians and can include lay members

question

Donut Hole

answer

-term applied to the difference b/t when first dollar coverage stops and insurance then begins -may be applied in a CDHP plan to the gap b/t the HRA or HSA, and when the high-deductible plan starts to cover costs -also exists in the basic Medicare Part D drug benefit passed under the MMA, at least at the time of publication

question

Gag clause

answer

a provision that may be incorporated in a physician's contract with MCO, which prevents him from being open with his patients about the terms of the patient's coverage and therapeutic options

question

Hold Harmless Clause

answer

a contract provision in which one party to the contract promises to be responsible for liability incurred by the other party

question

Case Mix

answer

-the mix of cases in an inpatient setting, accounting for differences in potential or real cost and outcomes -refers to a methodology of using case mix to evaluate performance of a provider or project potential costs

question

Reinsurance

answer

insurance purchased by a health plan to protect it against extremely high cost cases (also see stop loss)

question

Global Capitation

answer

the term used when an organization receives capitation for all medical services, including institutional and professional

question

Discuss 5 standard contracting provisions

answer

-Required qualifications & Credentials -Required compliance w/ the MCO's Utilization and Quality Mgmt Programs -"Hold Harmless" and "No Balance Billing" Clauses -Payment or Reimbursement terms -Term and Termination -Other party liability: Subrogation and Coordination of benefits

question

Name reasons that a MCO would cancel a contract

answer

-inadequate quality of care -failure to meet re credentialing requirements (every 10 years, may have lost license restricted) -business reasons (providers practice behavior unsuitable for a managed care environment)

question

What are 4 types of specialty hospital-based physicians (HBP)?

answer

-radiology, anethesiology, pathology, hospitalist (surgialist, ER medicine) -PCP, specialty care physicians, carve-out and specialty care services, HBP

question

5 basic elements for credentialing:

answer

-demographic information -office info -training (copy of certificates) -specialty care board eligibility or certification (copy of certificate) -current state medical license (copy) -NPI as required under HIPAA

question

What is the National Provider Identifier (NPI)?

answer

-mandated under HIPAA and replaced almost all other types of provider identifiers regardless of customer (commercial health plan, Medicare, Medicaid, TRICARE, etc) -is a 10 digit number and contains no embedded intelligence -contains no info about the health care provider -does not replace the DEA number or the tax ID number of a provider, however

question

Name 3 types of reimbursement to physicians:

answer

-Fee-for-service (most common) PPOs service plans, indemnity -Salary: closed panel -Stop-loss protection: the amount of costs generated is no longer used to measure the performance or determine the reimbursement of a physician

question

Discuss the reimbursement methods MCOs use for hospitals and institutions:

answer

-straight charges -discounts on charges -sliding scale discount charges -per diem charges -straight per diem charges -sliding scale per diem -straight DRGs -MS-DRGs -package pricing -capitation or % of Revenue

question

Discuss the various charges used by the Emergency Departments for payment of services:

answer

-straight discounts -sliding scale -bundled charges principal procedure code used by the facility, 2nd procedure is discounted b/c patient is already in facility and using services, outpatient cannot add several categories together for single patient encounter, rates covers all services, only one category at a time

question

What are the reimbursement methods for Ambulatory Services?

answer

-APGs (ambulatory patient groups) -APCs (ambulatory pt. classification) -both in public domain -based on procedure rather than diagnosis -adjusted by complexity and severity

question

What is P4P?

answer

-Pay for performance -providing financial incentives to providers -improve compliance w/ standards of care -improve outcomes & pt. safety -focus is on clinical performance -evidence based clinical practice -Measures quality: structure, process, and outcome -depends on a number of data collection sources

question

In Medicare, what type of P4P is used?

answer

-Physician Quality Reporting System (PQRS) -has 240 measures that eligible physicians would be assessed on based on their claims submissions as well as claims submitted by other providers, facilities, and ancillary services -physicians can also submit data from their EMR

question

What are the types of payment methods for Diagnostic and Therapeutic testing and Ancillary Services?

answer

-no significantly unique types of payment systems applicable only to ancillary services, some are less suitable than others -Flat Rate-fixed single payment -Capitation

question

What is the usual method of reimbursement for the PBM, Pharmacy Benefits Mgmt company?

answer

-Fill fee: amount that the PBM pays for filling the prescription -Ingredient cost: cost of the drug itself

question

How is a specialty pharmacy different from a traditional pharmacy?

answer

-Traditional: new research has led to an increase in use of drug therapy, new drugs are under patent and monopolized which leads to higher cost -Specialty: anything that is not standard formulary, requires physician intervention/ distribution, Biopharmaceutical, drugs used for uncommon conditions, cost is very expensive

question

Credentialing

answer

-obtaining and reviewing the documentation of professional providers -includes licensure, certification, insurance, evidence of malpractice insurance, malpractice history

question

(NPI) National Provider Identifier

answer

mandated under HIPAA and replaced almost all other types of provider identifiers regardless of customer

question

Stop Loss Protection

answer

form of reinsurance provides protection for medical expenses above a certain limit generally on a year by year basis

question

(MS-DRGs) Medicare Severity- Diagnosis Related Groups

answer

implemented by Medicare to replace traditional DRGs

question

Never Events

answer

medical error occurs in a facility (hospital or ambulatory surgical center) that should never happen

question

Bundled charges/ Packaged Pricing

answer

all inclusive rates paid for both institutional and professional services -hospital and institution reimbursement method

question

(NPDB) National Practitioner Data Bank

answer

established under federal health care improvement and quality act of 1986, electronically stores info about physician malpractice suits successfully litigated or settled, and disciplinary actions on physicians

question

(P4P) Pay for Performance

answer

-term applied to providing financial incentives to providers (hospitals and physicians) to improve compliance with standards of care, and improve outcomes and patient safety

question

(APGs) Ambulatory Patient Groups

answer

provide for a fixed reimbursement to an institution for outpatient procedures or visits and incorporate data regarding the reason for the visit and patient data -prevent unbundling of ancillary services

question

(APCs) Ambulatory Patient Classification

answer

-method that CMS settled on for implementing PPS reimbursement for ambulatory procedures -like the other methods, this is a way of clustering many different ambulatory procedure codes into groups for purposes of payment

question

Case Rates

answer

single payment encompasses all professional services delivered in an episode -i.e. obstetrics: prenatal visits, delivery, post natal, surgical procedure

question

(PQRS) Physician Quality Reporting System

answer

-it has 240 measures that eligible physicians would be assessed on based on their claims, submissions as well as claims submitted by other providers, facilities, and ancillary services -physicians can also submit data from their EMR

question

(AQA) Ambulatory care Quality Alliance

answer

P4P: sources of evidence based clinical process measures

question

(CAHPS) Consumer Assessment of Healthcare Providers and Systems

answer

-begun by federal govt for use in medicare and medicaid managed care plans, now also used by commercial health plans -maintained by AHRQ and required as part of NCQA accreditation process -initial focus was on managed health care plans, but is being expanded to ambulatory providers, hospitals, and the Medicare prescription drug program

question

(PBM) Pharmacy Benefit Manager

answer

-could be owned by the MCO or uses the services of a free standing facility -processes the claims for drugs submitted by the participating pharmacies -manages the formulary -monitors utilization

question

(EMR) Electronic Medical Record

answer

an electronic version of the type of health record that a physician or a hospital keeps on a single patient

question

(MMA) Medicare Modernization Act

answer

-federal act originally titled medicare prescription drug improvement and modernization act of 2003 -is the basis for both medicare part D drug benefit and for the variety of MA plans described elsewhere including MA local, MA regional, and MA PFFS

question

Generic drugs

answer

drug that is equivalent to a brand name drug but usually less expensive

question

Formulary

answer

listing of drugs that a health plan provides coverage for, but almost always at differing levels

question

(HBP) Hospital-Based Physician

answer

specialty physician who practices primarily w/ in a hospital or ambulatory surgical center in 1 of 3 clinical areas: radiology, pathology or who is a hospitalist

question

Data Transparency

answer

refers to an MCO or governmental agency making data about health care cost and quality available to consumers usually via the internet

question

Define utilization review and the purpose

answer

managing/overseeing, control costs & medical services ?

question

Name and explain the 3 components of UM

answer

-prospective (before): HRA, demand and referral mgmt, pre certification of institutional services -concurrent (during) -retrospective (after): case review, pattern analysis

question

Explain the types of measurements when evaluating utilization for healthcare

answer

-PMPM: per member per month -PMPY: per member per year -Per thousand (units of service)

question

Compare case manage with disease management (List 5 components of each):

answer

case mgmt: -emphasis on single patient -early identification of ppl with acute catastrophic conditions -applies to 0.5-1% of commercial membership -value relies heavily on price negotiations & benefit flexing -requires plan design manipulation -episode 60-90 day disease mgmt: -emphasis on population w/ chronic illness -early identification of all ppl w/ targeted chronic diseases (20-40) whether mild, moderate, severe -acuity level is moderate -applies to 15-25% of commercial membership -value due to member & provider behavior change that results in improved health status -requires no need to change plan design

question

What are ancillary services?

answer

-medical services not personally provided by physicians and are not hospital or institutional services -two common types are diagnostic & therapeutic services -ex: labs, radiology, CT scans

question

(CM) Case Management

answer

-method of managing the provision of health care to members with high-cost medical conditions -goal: coordinate the care so as to both improve continuity and quality of care and lower costs -dedicated function in UM department

question

(LOS) Length Of Stay

answer

length of stay

question

(DM) Disease Management

answer

-process of intensively managing a particular disease -encompasses all settings of care and places a heavy emphasis on prevention and maintenance -similar to case mgmt but more focused on a defined set of diseases

question

Preventive Services

answer

healthcare that is aimed at preventing complications of existing diseases or preventing the occurrence of a disease

question

Wellness Programs

answer

are directed at helping members to change their lifestyles and develop healthy habits

question

(HRA) Health Risk Appraisals

answer

instrument designed to elicit or compile information about the health risk of any given individual -now have become quite specialized and targeted toward particular populations with distinctive risk profiles

question

(DUR) Drug Utilization Review

answer

consists of activities and strategies for managing the volume and pattern of prescriptions -most common DUR strategy is to create prescribing profiles and provide the profile info to the physicians so they can compare their prescribing patterns w/ those of their peers -another common strategy is to require special authorization for certain drugs

question

(URAC) Utilization Review Accreditation Organization

answer

a not-for-profit organization that performs reviews on external utilization review agencies -primary focus is MCOs, though expanded accreditation activities -states often require certification by this or another accreditation organization to operate

question

Step therapy

answer

management of specialty pharmacy -MCOs use a combination of strict pre certification to ensure proper indicated use, DUR and step therapy using less costly drugs first, and negotiating with manufacturers to try to contain costs in this area

question

Name the 5 internal operations departments in the internal operation of a MCO:

answer

-marketing and sales -enrollment and billing -claims administration -member services -finance and underwriting -information technology (IT)

question

Explain the functions of a sales representative in an MCO

answer

-sales is the actual activity of selling to those in a position to buy -sales personnel are responsible for contacting the employers and meeting with the benefits manager -they find out employer's priorities when it comes to purchasing health care benefits for employees and to describe what the MCO offers that would be of value to the employer -relationships w/ brokers -all the activities that involve face-to-face dealing with customers are the domain of the sales staff

question

What are the channels of distribution of the MCO to market services and products?

answer

-MCO's own sales personnel: employed by MCO to represent them in marketplace -Benefits consultants: independent consulting firms work directly for an employer -Agents: independent licensed to sell -Brokers: independent -Direct self-service via the web: MCO's products and services to individual consumers

question

When an MCO markets their services, what must be observed in the components of commercial and government markets?

answer

-they have wholesale and retail components -wholesale: employers & govt agencies -retail: individual consumers -sales, growth, profitability, and incentive payments

question

Identify market size segmentation and the characteristics:

answer

-small employer groups: (2-50), represents largest number of employer firms -Midsized employer groups: (50-2,000), "middle market" -large employer groups: (2,000 +), many worksites in multiple states and needs many different options

question

Describe the functions of enrollment and billing:

answer

-ensures that new members are entered into the MCO's administrative IT systems, ID cards are generated and issued and so forth -ongoing maintenance of membership eligibility files is also a critical function for a variety of reasons

question

Name the basic elements of claims processing:

answer

-receive the claim, adjudicate the claim using automated tools (process), correct errors then run again, adjudicate manually those claims that cannot be processed automatically, write a check, inform the member and provider what was paid and what was not and finally archive all the information -determines if the person has coverage

question

Describe the claims function:

answer

-claims capture (usually electronic & directly from providers) -basic benefits administration -determining level of coverage -pricing claims payment -application of medical policies -routine medical policies -medical policies for exceptions -management of pended or appealed claims and adjustments -other party liability -management of claims inventory -payment and evidence of benefit statements -archiving -productivity and quality management -Responsible for ensuring that the providers are paid for their services and that members receive reimbursements

question

What are medical policies?

answer

-rules to make payment decisions -regarding routine care and exceptions, rules used for using clinical info to make commonplace claims payment decisions

question

What are the advantages of electronic funds transfer?

answer

paid faster, less chance of getting lost

question

Name the responsibilities of member services and why are they so important?

answer

-direct contact with members: general info and outreach -routine communication -continual surveillance

question

In the finance department of an MCO, what are their duties and why are they so important?

answer

-make money $$$$ -per member per month -responsible for managing the money

question

How does the treasury department operate in an MCO?

answer

-responsible for actually managing the cash and investments of the MCO -must maintain adequate financial reserves to cover the cost of the claims using "risk-based capital" formula

question

Explain the functions of the budgeting department and define the 2 necessary components of the operating budget categories:

answer

-the need to create a budget for medical expenses and a separate one for operational expenses -Operational -Reporting

question

Discuss the various forms of rating the underwriters use to calculate the actual premium rates charged to customers:

answer

-rating for self insured employers: "premium equivalent" rates -standard community rating: same charge for everyone -adjusted community rating & community rating by class: adjusted based on variables -Experience: medical experience of the employer group

question

Distribution

answer

an informal term used to describe the various ways that an MCO sells its products- for example, brokers, consultants, employed sales force, electronic sales portals, and so forth.

question

Marketing

answer

-the first critical operational activities an MCO must undertake are to market its services and sell its products -involves creating a strategy for entering a market and building the infrastructure needed to sell the MCO's services

question

Benefits consultants

answer

-are independent consulting firms that work directly for an employer -focus almost exclusively on large employers and receive a consulting fee from the employer that is not related to the premium cost of insurance and is paid on a one-time basis -evaluate proposals from various MCOs against many criteria to help large employers make the best choices for employee benefits -also negotiate with an MCO on behalf of their clients

question

Adjudicate

answer

the management and processing of claims by an MCO or health insurance company

question

Claims capture

answer

-first function performed by the claims department is to capture the claim which means entering a received claim into the claims processing system -claims come in from a variety of sources, most common are electronic submissions using nationally standardized electronic claims forms, U.S. mail, less common sources are faxes, secure email, self entry via web -claims usually come directly from providers -submitted claims must contain certain pieces of info or they will be rejected by any MCO

question

Archiving

answer

-final step in the process (claims & benefits admin.) is storing all the info used to adjudicate the claim, as well as info about how it was finalized -records extremely important, esp. in cases of appeals & grievances or in the event of a lawsuit -extremely sensitive, so great care is taken to protect privacy -is electronic -done both on-site at the MCO for ease of retrieval, and off-site as a secure location so that in the event of a disaster, the MCO can still recover necessary info

question

(EOC) Evidence Of Coverage

answer

-also known as a certificate of benefits -document that describes the health care benefits covered by the health plan -provides the member with some form of documentation that he or she in fact does have health insurance, and it describes what that insurance covers and how it works

question

(OPL) Other-Party Liability

answer

an agreement that uses language developed by the National Association of Insurance Commissioners and prevents double payment for services when a subscriber has coverage from two or more insurance companies or MCOs

question

(FSA) Flexible Spending Accounts

answer

-financial account that is part of a Section 125 plan, funded with pretax dollars via payroll deduction by an employer -funds may be used to reimburse the employee for

question

(IBNR) Incurred but not reported

answer

the amount of money that the plan had better accrue for medical expenses that it knows nothing about yet -these are medical expenses that the authorization system has not captured and for which claims have not yet hit the door

question

(EFT) Electronic Funds Transfer

answer

getting paid by electronic transfer of funds directly to one;s bank instead of receiving a paper check

question

(RBRVS) Resource-Based Relative Value Scale

answer

this is a relative value scaled developed for the CMS for use by Medicare -assigns relative values to each CPT code for services on the basis of the resources related to the procedure rather than simply on the basis of historical trends -practical effect has been to lower reimbursement for procedural services (surgery) and to raise reimbursement for cognitive services (office visits)

question

Underwriting

answer

-refers to bearing the risk for something (a policy is underwritten by an insurance company) -in another definition, this refers to the analysis of a group to determine rates and benefits or to determine whether the group should be offered coverage at all -a related definition refers to health screening of each individual applicant for insurance and refusing to provide coverage for preexisting conditions

question

What is Medicare?

answer

health care benefits for the elderly, for persons with end-stage renal disease and for some disabled persons

question

Describe Parts A and B of Medicare:

answer

-A: benefits for hospital services -B: benefits for medical services

question

What is Medicaid?

answer

-health insurance for low income individuals -also provides major subsidies to safety net hospitals to provide uncompensated care to millions of uninsured people -administered by the state

question

Who is eligible for Medicaid?

answer

-policies, rule, and regulations pertaining to eligibility, coverage, and payment and services vary from state to state -low income individuals, mostly healthy women and children, who make up 70% of the enrollees -aged and younger persons who have chronic illnesses and are disabled (2nd largest group) -institutionalized individuals

question

Explain the Balanced Budget Act of 1997 (BBA):

answer

-expanded the benefits options and the plans available under Medicare to include Medicare HMOs, PPOs, POS, PFFS (private fee for service), PSO and MSAs -ultimately led to Medicare+ Choice program

question

Define the Medicare Prescription & Drug Improvement and Modernization Act:

answer

AKA Medicare Modernization Act (Medicare Part B) -added drug coverage to Medicare

question

How did MMA impact health plans?

answer

-it provided more money for health plans in a variety of ways, also introduced a new approach to plan contracting: PPO's, multiple benefits plan

question

States monitor their Medicaid programs through what measurement tool

answer

HEDIS

question

Explain the Medicare Advantage (MA) program

answer

able to enroll HMO's, adjusted payments, created payment for HMOs and PPOs, bidding

question

Explain the special requirements for the MA plans

answer

license in the state it operates

question

(PFFS-MSA) Private fee for service- medical savings account

answer

type of medicare advantage plan in which a private insurance company accepts risk for enrolled beneficiaries but pays providers on FFS basis that does not have any risk component to the provider

question

(PCCM) Primary Care Case Manager

answer

used in Medicaid managed care programs and refers to the state designating PCPs as case managers to function as gatekeepers, but reimbursing those PCPs using traditional medicaid fee for service and paying the PCP a nominal management fee, such as 2-5$ PMPM

question

(CCIP) Chronic Care Improvement Program

answer

-identifies enrollees with multiple or sufficiently severe chronic conditions who meet the criteria for participation in the program, and the program must have a mechanism for monitoring enrollee's participation

question

(SCHIP) State Children's Health Insurance Program

answer

a program created by the federal government to provide a "safety net" and preventive-care level of health coverage for children, funded through a combination of federal and state funds and administered by the states, through Medicaid in conformance with federal requirements

question

Dual Eligible

answer

individuals who are entitled to both Medicare and Medicaid coverage

question

(DME) Durable Medical Equipment

answer

medical equipment that is not disposable and is only related to care for a medical condition

question

(MA-PD) Medicare Advantage- Prescription Drug

answer

medicare advantage prescription drug

question

(OIG) Office of Inspector General

answer

federal agency responsible for conducting investigations and audits of federal contractors or any system that receives funds of reimbursement from the federal government

question

(SNP) Special Needs Plan

answer

a type of MA plan -may exclusively enroll, or enroll a disproportionate percentage of, special needs Medicare beneficiaries

question

(MSA) Medical Savings Account

answer

-created under BBA 97' and updated in the MMA -are specialized savings accounts into which a consumer can put pretax dollars for use in paying medical expenses in lieu of purchasing a comprehensive health insurance or managed care product

question

(ESRD) End Stage Renal Disease

answer

Medicare treats beneficiaries with this differently than other types for purposes of enrollment in MA plans

question

What are the issues with state regulation of managed care?

answer

laws and regulations not only differ between states, but also the type of MCO being regulated

question

Explain how HIPAA of 1996 impacted the insurance industry:

answer

it placed requirements and regulatory responsibilities on almost all elements of the HC system, including providers and MCOs, regardless of any other state or federal legislation

question

What are the 2 separate Federal laws that provide individual extended health care with an insurer if they lose group benefits?

answer

HIPAA ERISA

question

Identify the 3 clinical conditions HIPAA adopted in the late 1990s through amendments or acts to the original act:

answer

-newborn and mothers health protection act of 96- minimum 48 hour stay for normal vaginal deliveries, 96 hours C section -mental health parity act- requires aggregate lifetime dollar limits and annual dollar limits for mental health benefits and medical-surgical benefits be equal -the womens health and cancer right act- group health plans cover medical and surgical benefits for mastectomies, etc.

question

The HIPAA law addresses administrative simplification. Explain this component and the goals:

answer

-most important section -reduce admin cost and burden in HC, standardize certain data elements, and protect the privacy of individual health info -4 basic elements: transactions & code sets, NPI, privacy of medical info, security of medical info

question

Define the standard code sets used by HIPAA:

answer

-the transactions in question are electronic transfers of data between providers and payers amongst others and the code sets are the definition of data -we want uniform national standard for electronic transactions

question

Briefly explain the privacy provisions on health information by HIPAA (Identify 6) :

answer

-state provisions are allowed to be much more strict then HIPAA -protected health info (PHI) -consumer control over health info (patients have the right to understand and control how their health info i used) -limits on medical record use and release -admin requirements ???

question

ERISA must adhere to very limited regulations by state and federal law. Define these regulations:

answer

-Exclusions for preexisting conditions -waiting periods for coverage -COBRA benefits extension requirements -HIPAA requirements -Coverage of children -Pediatric vaccinations -Coverage for mental health services, maternity care, mastectomies

question

All MCOs are required to have a formal grievance and appeals process. What are the minimum requirements under ERISA:

answer

-Timelines of response -Who will receive the grievance or appeal -Limitations on how long a member has to file a grievance or appeal -What recourse a member has

question

Define the 3 organizations that have developed managed care oversight programs:

answer

NCQA-National Committee on Quality Assurance URAC- Utilization Review Accreditation Commission AAAHC-Accreditation Association for Ambulatory Health Care

question

Name the industry standard for reporting data to employers and some government agencies:

answer

HEDIS

question

P4P: Sources of evidence based clinical process measures:

answer

-HEDIS -CAHPS -AQA -NCQA

Ch 1-3 Pt. Care MGMT. – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards