Podcast
Questions and Answers
What is a primary reason that healthcare insurance companies became involved with healthcare costs?
What is a primary reason that healthcare insurance companies became involved with healthcare costs?
Which of the following statements regarding healthcare benefits is correct?
Which of the following statements regarding healthcare benefits is correct?
What is a health insurance premium for an employee with two children, based on the scale provided?
What is a health insurance premium for an employee with two children, based on the scale provided?
When seeking healthcare benefits, what is an important factor to consider?
When seeking healthcare benefits, what is an important factor to consider?
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What additional coverage might incur extra premiums deducted from an employee's paycheck?
What additional coverage might incur extra premiums deducted from an employee's paycheck?
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What factors can lead to a provider not renewing their contract with a managed care company?
What factors can lead to a provider not renewing their contract with a managed care company?
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What is one potential consequence of not meeting established deadlines in patient care?
What is one potential consequence of not meeting established deadlines in patient care?
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How do managed care companies typically determine reimbursement rates for healthcare providers?
How do managed care companies typically determine reimbursement rates for healthcare providers?
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What happens if a patient chooses to see a provider that is 'out of network'?
What happens if a patient chooses to see a provider that is 'out of network'?
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What is a common problem that practices face when managing billing and insurance requirements?
What is a common problem that practices face when managing billing and insurance requirements?
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Why do managed care companies employ personnel to negotiate contracts with hospitals?
Why do managed care companies employ personnel to negotiate contracts with hospitals?
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In a self-employed practice, which cost would be considered part of overhead?
In a self-employed practice, which cost would be considered part of overhead?
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What can occur if group practices do not hold regular business meetings?
What can occur if group practices do not hold regular business meetings?
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How long can it take for managed care companies to process reimbursements after a patient visit?
How long can it take for managed care companies to process reimbursements after a patient visit?
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What usually occurs when managed care companies make payment changes?
What usually occurs when managed care companies make payment changes?
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What does the member ID on the healthcare coverage ID card identify?
What does the member ID on the healthcare coverage ID card identify?
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What are employers primarily concerned with regarding healthcare premiums?
What are employers primarily concerned with regarding healthcare premiums?
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What is a deductible?
What is a deductible?
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How often is the provider and managed care contract valid?
How often is the provider and managed care contract valid?
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What is generally required when joining a provider group?
What is generally required when joining a provider group?
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What is a co-pay?
What is a co-pay?
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What happens if a provider is not accepted into a managed care plan?
What happens if a provider is not accepted into a managed care plan?
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What amount is typically shared equally between employees and employers for healthcare premiums?
What amount is typically shared equally between employees and employers for healthcare premiums?
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What usually happens after a provider submits their application to a managed care company?
What usually happens after a provider submits their application to a managed care company?
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What is typically included in the provider contract?
What is typically included in the provider contract?
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What is the primary reason health insurance companies emphasize managing costs within healthcare?
What is the primary reason health insurance companies emphasize managing costs within healthcare?
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What determines whether an employee's spouse can obtain healthcare benefits through their work?
What determines whether an employee's spouse can obtain healthcare benefits through their work?
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Which of the following accurately describes the impact of layoffs on healthcare benefits for employees?
Which of the following accurately describes the impact of layoffs on healthcare benefits for employees?
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Which factor is NOT typically considered when determining the scale of healthcare premiums for employees?
Which factor is NOT typically considered when determining the scale of healthcare premiums for employees?
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What additional form must an employee fill out if they wish to obtain dental coverage?
What additional form must an employee fill out if they wish to obtain dental coverage?
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What is a typical financial arrangement between an employee and employer regarding healthcare premiums?
What is a typical financial arrangement between an employee and employer regarding healthcare premiums?
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What must a provider submit along with their application to a managed care company?
What must a provider submit along with their application to a managed care company?
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What best describes a deductible in the context of healthcare insurance?
What best describes a deductible in the context of healthcare insurance?
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What is a common co-pay amount for outpatient services?
What is a common co-pay amount for outpatient services?
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How frequently must the provider and managed care contract be renewed?
How frequently must the provider and managed care contract be renewed?
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What might be included in the managed care provider contract regarding malpractice?
What might be included in the managed care provider contract regarding malpractice?
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What happens once the legal contract with a managed care company is signed?
What happens once the legal contract with a managed care company is signed?
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What is considered a bridge service regarding healthcare coverage?
What is considered a bridge service regarding healthcare coverage?
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What is a crucial step prior to submitting an application to a managed care company?
What is a crucial step prior to submitting an application to a managed care company?
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What does the ID number on the healthcare coverage card signify?
What does the ID number on the healthcare coverage card signify?
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What is a possible consequence of hiring too many office staff in a healthcare practice?
What is a possible consequence of hiring too many office staff in a healthcare practice?
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Which of the following statements best describes the relationship between managed care companies and providers?
Which of the following statements best describes the relationship between managed care companies and providers?
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How do managed care companies maintain their networks of providers?
How do managed care companies maintain their networks of providers?
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What is one of the main reasons for delays in reimbursement from managed care companies?
What is one of the main reasons for delays in reimbursement from managed care companies?
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Why might a patient incur higher costs when seeing an 'out of network' provider?
Why might a patient incur higher costs when seeing an 'out of network' provider?
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What difficulty arises when a patient needs a procedure that is referred by a primary care physician?
What difficulty arises when a patient needs a procedure that is referred by a primary care physician?
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What type of billing practices can jeopardize a provider's relationship with managed care companies?
What type of billing practices can jeopardize a provider's relationship with managed care companies?
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What is essential for group practices to avoid rapid turnover in positions?
What is essential for group practices to avoid rapid turnover in positions?
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Which factor is primarily influenced by managed care companies in determining provider payment?
Which factor is primarily influenced by managed care companies in determining provider payment?
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Study Notes
Managed Care: Overview
- Managed care companies manage healthcare costs for their members, typically obtained through employer-sponsored plans.
- Most individuals obtain health insurance through their employment.
- Employers often negotiate with managed care companies to lower costs by sharing premiums with their employees.
Managed Care Plans and Benefits
- Managed care plans are typically divided into categories, e.g., employee-only, employee + spouse, employee + one child, etc.
- Employees pay healthcare premiums through payroll deductions.
- Dental and vision coverage are often optional and require additional premiums.
Member Identification
- Members receive an ID card with a group number (identifying the employer plan) and a member ID (identifying the individual).
Deductibles
- Deductibles are the amount a patient must pay out-of-pocket before coverage begins.
- Deductibles are negotiated between the employer and the managed care company.
Co-Pays
- Co-pays are fixed amounts paid at the time of service, often for outpatient visits.
- Negotiated between the employer and managed care company.
Provider Network
- Providers must contract with managed care companies to participate in their network.
- Providers must meet various requirements to receive payment from managed care companies, including:
- Submitting copies of licenses and qualifications
- Providing references
- Undergoing background checks
- Signing a comprehensive contract outlining terms of service
- Providing malpractice insurance information
- Providers must adhere to managed care company guidelines, including billing practices and appointment scheduling.
Reimbursement Rates
- Managed care companies establish reimbursement rates for contracted providers based on standardized codes.
- Reimbursement rates are subject to change, potentially impacting provider income.
- Managed care companies typically negotiate contractually with hospitals to reduce healthcare costs further.
Challenges in Managed Care
- Managed care companies require providers to submit extensive documentation and adhere to specific guidelines, adding administrative burden.
- Profit margins for providers, especially in private practice, can be significantly affected by reimbursement rates and unpredictable patient volume.
- The potential for delayed reimbursement and the need to carefully manage overhead costs are crucial for provider financial stability.
- Group practices benefit from regular business meetings to ensure transparency, and proper decision-making.
Managed Care
- Managed care companies emerged due to rising healthcare costs.
- Most individuals receive healthcare benefits through employment, with full-time workers being eligible.
- Healthcare premiums are deducted from employees' paychecks and typically increase based on the number of dependents covered.
- Healthcare coverage includes medical and mental health benefits, with dental and vision being optional at an additional cost.
- Employees receive healthcare coverage ID cards with unique group and member numbers.
- Employers negotiate premiums with managed care companies to minimize costs for both employees and themselves.
- Deductibles are the amount patients must pay before insurance coverage begins.
- Co-pays are fixed payments made at the time of service, typically for outpatient care.
- Providers must apply to join managed care networks, providing documentation and undergoing a background check.
- Provider contracts outline the terms of participation, including malpractice insurance requirements.
- Managed care companies do not advertise participating providers, leaving it to patients to find in-network options.
- Provider contracts are typically valid for one year and require renewal, which involves verifying licenses and meeting deadlines.
- Providers may lose their contracts with managed care companies for reasons such as disciplinary actions, non-compliance, or billing fraud.
- Private practices face challenges with billing processes, reimbursement delays, and income variability.
- Group practices require regular business meetings to ensure transparency and cohesion.
- Managed care companies are responsible for maintaining networks of providers.
- Patients who see providers outside of their managed care network ("out of network") may face higher out-of-pocket costs.
- Hospitals negotiate reimbursement rates with managed care companies, which can vary slightly.
- Managed care companies have contracted relationships with hospitals and providers, which can create complexities for patients.
- Common challenges for providers include excessive administrative burdens related to billing and insurance.
- Late submission of billing information can result in non-payment.
- Private practices have greater financial uncertainty compared to salaried positions due to variable patient volume.
- Overhead costs include employee salaries and other operating expenses.
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Description
This quiz provides an overview of managed care, focusing on how healthcare costs are managed for members through employer-sponsored plans. It covers the various types of managed care plans, member identification processes, and the role of deductibles in healthcare coverage.