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Questions and Answers
Questions and Answers
What is an organization through which employer health benefit plans and health insurance carriers contract to purchase healthcare services for covered beneficiaries from a selected group of participating providers?
What is an organization through which employer health benefit plans and health insurance carriers contract to purchase healthcare services for covered beneficiaries from a selected group of participating providers?
- Preferred Provider Organization (correct)
- Health Maintenance Organization
- Exclusive Provider Organization
- Managed Care Organization
What is a group practice without walls?
What is a group practice without walls?
A physician organization formed for the purpose of sharing some administrative and management costs while continuing to practice at their own locations.
What is a review that is performed during the course of treatment referred to as?
What is a review that is performed during the course of treatment referred to as?
Concurrent review
What is the purpose of the Health Care Quality Improvement Act?
What is the purpose of the Health Care Quality Improvement Act?
What is Antitrust implication when a managed care organization possesses significant market share?
What is Antitrust implication when a managed care organization possesses significant market share?
What is a prospective review system?
What is a prospective review system?
What is managed care?
What is managed care?
What is a physician-hospital organization?
What is a physician-hospital organization?
The Employment Retirement Income Security Act (ERISA) regulates the contents of the welfare benefit plans.
The Employment Retirement Income Security Act (ERISA) regulates the contents of the welfare benefit plans.
According to the VA healthcare system, NC is in which veterans integrated service network (VISN)?
According to the VA healthcare system, NC is in which veterans integrated service network (VISN)?
Which of the following is the process whereby a third-party payer evaluates the medical necessity of a course of treatment?
Which of the following is the process whereby a third-party payer evaluates the medical necessity of a course of treatment?
What did Congress enact to increase the number of Americans covered by health insurance by approximately 30 million people?
What did Congress enact to increase the number of Americans covered by health insurance by approximately 30 million people?
Vertically integrated delivery systems were envisioned to provide comprehensive care to patients.
Vertically integrated delivery systems were envisioned to provide comprehensive care to patients.
Match the following laws with their purpose:
Match the following laws with their purpose:
Which title of the ACA has not been implemented by the Secretary for Health and Human Services?
Which title of the ACA has not been implemented by the Secretary for Health and Human Services?
ERISA does not cover group health plans established or maintained by government entities or churches.
ERISA does not cover group health plans established or maintained by government entities or churches.
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Study Notes
Study Notes
Managed Care Concepts
- Preferred Provider Program: An organization facilitating employer health benefit plans to purchase healthcare services from a select group of providers.
- Group Practice Without Walls: A physician organization helping to share administrative costs while allowing physicians to continue practice at their own locations.
Reviews and Regulations
- Concurrent Review: A treatment evaluation conducted during the course of treatment.
- Utilization Review: Process by which third-party payers assess the necessity of a treatment course.
- Health Care Quality Improvement Act: Provides limited immunity to individuals giving information to professional review bodies regarding adverse effects on physician staff privileges.
Market Dynamics
- Patient Protection and Affordable Care Act (ACA): Enacted by Congress, resulting in coverage for approximately 30 million Americans and reducing insurance costs.
- Antitrust Implications: Arise when managed care organizations have significant market share, with potential violations related to price fixing.
Healthcare Delivery Systems
- Physician-Hospital Organization: Joint venture between physicians and hospitals aimed at improving cost management and expanding community healthcare resources.
- Vertically Integrated Delivery System: Provides a range of services from primary outpatient to tertiary inpatient care.
Health Insurance Plan Types
- Prospective Review System: A payer decides on treatment reimbursement before it is provided.
- Types of Managed Care Plans:
- Point of Service Plans: Utilize primary care physicians as gatekeepers to manage healthcare.
- Exclusive Provider Organization: Limits beneficiaries to participating providers for all healthcare services.
- Specialty HMOs: Offer limited healthcare coverage components, often focusing on specific areas like dental.
- Independent Practice Association: A legal entity of physicians negotiating contracts for services.
Legal and Regulatory Framework
- Employee Retirement Income Security Act (ERISA): Does not cover government or church health plans, nor those maintaining compliance solely with worker's compensation or disability laws.
- Stark Law: Prohibits physician referrals to clinical laboratories if they have ownership interests or compensation arrangements with those labs.
Other Notable Points
- NC in Veterans Integrated Service Network (VISN): North Carolina is part of the 6th VISN according to the VA healthcare system.
- Titles of the ACA: There are ten titles associated with the ACA, with some not implemented by the Secretary for Health and Human Services.
True or False Statements
- Vertically Integrated Delivery Systems: Designed to deliver comprehensive care from primary to long-term care facilities, sometimes including insurance components.
- ERISA's Scope: True that ERISA does not cover certain group health plans established by governmental or church entities.
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