462 midterm exam review study guides PDF

Preview

Summary

Exam prep for HSA major will be used as a study guide upon completion of this course. Take notes as they will talk about this stuff in-class review....

Description

Chapter 11. What type of arrangement is considered the forerunner of what we now call health maintenance organizations? The Ross-Loos Clinic, which many believe to be the first true “HMO”

2. What is the impetus for the early development of HMOs? Paul Elwood, MD, was asked by leaders in the Nixon administration to create ways to stem the rising Medicare budget in the face of the failure to enact national health insurance overall

3. What were the early characteristics of BC/BS plans? prepaid hospital care to teachers – the origins of Blue Cross lumber and mining company employees – the origins of Blue Shield

4. What is the trend with healthcare cost inflation?

5. What is ERISA? ● Employee Retirement Income Security Act ● ERISA does not directly address managed care, it does address employee benefits plans, including health benefits plans ● Origin of self-funding option for employers offering benefits plans – Currently over half of coverage in commercial sector is self-funded ● Employer funds the cost of health claims, not the insurer ○ Claims paid using employer’s money, not insurer’s ○ Employer purchases stop-loss insurance for catastrophic costs ○ Benefits plan is administered by a large health plan such as a BCBS plan or large commercial carrier ● Codifies several requirements to be discussed later in course, such as appeal rights, non-discrimination, etc. 6. Health care cost inflation is attributed to

7. Features of the HMO Act: ● Moving away from fee for service ● Provisions of preventative care

● ● ●

Applied to commercial sector Term “health maintenance organization” coined to focus on maintaining health Key features included comprehensive benefits (but not Rx)

8. How do PPOs and HMOs differ?

9. What is an Integrated Delivery System? Built for Stronger negotiating position when contracting with HMOs and the Ability to take on risk for medical costs

10. In the 80’s and 90’s what impact did HMO’s have on indemnity plans? Worksite wellness programs become increasingly prevalent •Utilization management and on-site hospital concurrent review become widespread •For-profit HMOs appear •Passage of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), which finally authorizes Medicare HMOs •Passage of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), providing limited health insurance conversion rights •Diagnosis Related Groups(DRGs) implemented in Medicare– creating prospective payment for hospital services in FFS Medicare

11. What are the key components of managed care?

12. Define managed care

13. In a Point of Service (POS) plan, members have:

14. What was the major consolidation trend in the 1990s? Hospital systems merge on a regional basis, giving them greater negotiating leverage, and some BCBS plans convert to for profit and begin to consolidate. 15. The Health Insurance Portability and Accountability Act limits the ability of health plans to••

16. The impact of the managed care backlash includes: ● A reduction in HMO membership ● New federal and state laws and regulations

17. What are the major provisions of the ACA?

18. The major impetus behind the passage of the Affordable Care Act include:

19. What act authorized the creation of accountable care organizations (ACOs)?

20. What is an ACO?

21. What are the hospital consolidation trends?

22. Study the Conclusion Section

CHAPTER 21. What are the five types of people or organizations that make up the US healthcare system? 1. Individuals a. Members b. Beneficiaries c. Patients d. Uninsured 2. Providers 3. Manufactures 4. Payers 5. Regulators

2. What type of health plan provides health care? Group and staff model HMOs Some large integrated healthcare delivery systems (IDSs) that sell coverage through a subsidiary licensed payer company, and payers that acquired physician practices and/or hospitals 3. What are the three core components of healthcare benefits? 1. Defined benefits 2. Cost Sharing 3. Coverage limitations

4. What is a defined contribution plan? A defined contribution plan means the amount of money is defined, not the benefit; for example, a “mini-med” plan pays you $300.00 per day if you’re in the hospital regardless of what it costs you, but you pay the rest yourself 5. Identify examples of the types of defined health benefits plan:

6. What are state-mandated benefits and to what types of plans do they apply?

7. Define the types of cost-sharing Copayment- a fixed amount of money per type of service (ex- $30 each time a member goes to the doctor) Coinsurance- a percentage of the total dollar amount that is covered (ex- 20% of the payment amount to a hospital for an inpatient stay, based on in-network payment rates) Deductible- a fixed amount of money that a member must pay out-of-pocket before any coverage begins to apply (ex- a $1,000 deductible for hospital stays) 8. What are the ACA cost sharing levels? Platinum- 10% or less total cost sharing Gold- 20% total cost sharing Silver- 30% total cost sharing Bronze- 40% total cost sharing

9. What are entitlement programs? In the US approximately 40% of all national health expenditures were paid by the federal and state entitlement programs. Coverage is provided to anyone who is eligible to get it, meaning that person is entitled to that coverage. Government entitlement programs, which may or may not include all or some managed care features, include the following: Medicare Medicaid Uniformed Services through TRICARE Veterans Administration Indian Health Service

10. What type of health plans are the largest source of health coverage? Employer based group health benefits plans are the largest source of health benefits coverage in the US (almost half of all coverage) 11. What are the advantages of group health benefits plans? ● The cost of the coverage is paid on a pretax basis

● ● ● ● ●

Employers can either purchase group health insurance or self-fund the benefits plan Employers, especially large employers, are usually able to obtain more favorable pricing and coverage than individuals can Large employers often provide employees with different opinions for type of health plan or amount of cost sharing Healthcare coverage benefits may be combined with other types of benefits (EX; flexible spending accounts, health payment accounts, or life insurance) The employer-not the individual employee- manages administrative needs such as payroll deductions and payment of premiums

12. What are the sources of benefits coverage and risk?

13. What is bearing risk?

14. What is provider risk?

15. What is reinsurance? REINSURANCE IS NOT HEALTH INSURANCE Reinsurance is a type of insurance that insures the party bearing risk, but it applies only to very high-cost cases or higher than predicted overall costs 16. Study and understand the continuum of managed care (figure 2-1) ● •Indemnity insurance● •Service plans● •Risk-bearing PPOs● •Non-risk-bearing PPOs● •HDHP (CDHP)- more of a benefits design than a type of managed care plan ○ Generally first dollar coverage for prevention ○ High deductible is just that- a very large deductible, and significant cost sharing (amount determined annually by the US treasury ○ CDHPs combine a HDHP with a pre-tax savings vehicle■ Health reimbursement account (HRA) ■ Health savings account (HSA) ○ Often linked to a PPO ○ Fit comfortable on ACA’s bronze level of benefits ● •Point of Service plans- mandatory for HMOs in some states ○ POS turns out to be expensive ● •Open-access HMOs- do not use the PCP model, and are now uncommon ● •Closed-Panel HMOs- medical group and staff model 17. What are the two types of traditional health insurance?

18. What are characteristics of PPOs? ● Currently the dominant form of health plan ● Network smaller than total use of providers ● Better coverage benefits when using participating providers (ex- 80/20 in-network, 60/40 out-of-network ● Responsibility for complying with medical management○ Responsibility of participating provider for in-network ○ Responsibility of member for out-of-network ● Plan sponsored vs. provider sponsored 19. What are the commonly recognized types of HMOs? ● Open panel HMO ○ IPA model ○ Direct contract ● Closed panel HMO ○ Group model ○ Staff model ● Mixed model HMO 20. What are the defining feature of a direct contract model ● HMO contracts directly with MDs and hospitals ● HMO may capitate some providers ● Payment often differs by different types of providers ● HMO conducts medical management 21. What are the advantages of an IPA? ● IPA contracts with MDs ● HMO contracts with IPA ● How IPA is paid may not match how MDs are paid ○ HMO capitates IPA ○ IPA pays FFS to MDs ● IPA may or may not conduct medical manegemet 22. What is the differences between an open plan HMO versus a closed plan HMO? ● Open panel HMO○ Independent practice association (IPA) ○ Direct contract ○ Term “IPA” often used even in a direct contract model plan ○ Term ”network” often used for open panel plans ● Closed panel HMO○ Medical group model ○ Staff model

23. What is a third party administrator? TPAs provide bare bones administrative services to self-funded employer groups •Does not take risk and All services a la carte

CHAPTER 31. Identify the basic elements for a provider contract. •Names and legal description of the contracting entities •Table of contents •Definitions •Relationship of the parties •Use of name •Notification •Insurance and indemnification •Declarations, closing, etc. •Term, often evergreen until notification •For-cause reasons for suspension or termination ● Non-Negotiable Terms Required by Laws and Regs•No Balance Billing •Hold Harmless •Compliance with CM and UM programs •Maintenance of clinical standards, licensure, malpractice insurance, etc. •Maintenance and retention of records •Non-discrimination requirements •Compliance with privacy and security requirements •Acceptance of minimum number of patients from plan •Compliance with certain administrative requirements such as timely billing, access to records, addressing patient/member complaints, etc. •Compliance with Other Party Liability processes •“Flow down” clauses and provider subcontracts for non-negotiable elements 2. What is a service area and to which plans does it apply? ● A service area is just an expression of network adequacy requirements, meaning: ○ Service areas apply primarily to HMOs, MA, and managed Medicaid plans ○ Service areas may apply to non-Medicare PPOs in some states, but usually not ● A plan’s service area means the geographic area the plan meets its provider access requirements, at least for major types of providers 3. What are the considerations for successful network development?

4. Exhibit 3-: Recognize the various types of physicians and other providers found in payer networks.

5. What is credentialing? ● Physician Credentialing ○ Relatively standardized set of criteria for credentialing and recredentialing physicians ○ The Data Bank (National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank) ○ Credentials must be verified either by payer or by an accredited credentialing verification organization (CVO) ○ Until 2009, HMOs performed on-site office visits for primary care, OB/Gyn and high volume behavioral health providers; now done only if identified concern ○ Re-credentialing occurs every three years, based on a subset of the original credentialing data 6. Table 3.2: Recognize the basic elements of credentialing Demographics such as name, birth date, location, and so forth

Participation status with Medicare and Medicaid programs

Medical license number and expiration date for each state in which the physician is licensed

Ambulatory surgical center privileges

Drug Enforcement Agency number and expiration date, state prescribing number and expiration date if a state requires it

Professional liability insurance

National provider identifier (NPI – see Chapter 6), tax ID, other applicable legal or regulatory identifiers

History of malpractice awards and settlements

Education and training dates, locations, and degrees or certifications earned

History of professional sanctions and other adverse events

Specialty board certification(s) and expiration date(s)

Work history and references

Practice details

Billing and remittance information

Hospital privileges

Disclosure questions

7. What are the types of physician contracting situations? ● Individual physicians – numerically most common, but shrinking fast ● Independent medical groups – growing, as practices consolidate and hire ○ Medical groups are all or none, meaning all physicians must be in or there will be no contract with the group ○ Small groups similar to individual physicians

●

○ Larger multi-specialty groups are more complex, provide more services ○ Physicians often paid via salary with incentives ○ Groups usually the best at managing capitation Hospitals, and some HMOs, may use a captive medical group that is little different from direct employment

8. Table 3-3: Recognize the common types of IDSs and their relationships with Independents and Employed Physicians Type of IDS

Relationship to Independent and Employed Physicians

Physician-hospital organization (PHO)

Used almost exclusively with independent physicians. The physicians may participate as individuals, medical groups, GPWWs, or some combination. Physicians may also participate solely through an IPA. PHOs are not always true IDSs, though they can be.

Management services organization (MSO)

Described earlier, MSOs are used primarily with independent physicians but may be used when physicians are indirectly employed or otherwise exclusive to the IDS. An MSO can also be combined with a GPWW or an IPA.

Foundation, GPWW, and captive medical groups

Described earlier, GPWWs are used primarily for physicians employed indirectly due to state laws prohibiting the employment of physicians by non-physicians. It is also used to more easily bill for services by employed physicians, separate from other services. A GPWW may also be used for physicians employed by an entity other than a hospital. All of these models may be combined with an MSO.

Patient-centered medical home (PCMH)

Originally conceived as geared toward independent physicians, it can apply now to both independent and employed physicians, including both at the same time.PCMH is listed here because they are a type of IDS, but are addressed in Chapter 5, not here.

Accountable care organization (ACO)

Can apply to both independent and employed physicians, including both at the same time, and will mirror the distribution of independent and employed physicians who provide care at the hospital system. Some IDSs may choose to focus their ACO primarily on their employed physicians, however.

MHS with Employed Physicians in Multiple Specialties

This is a truly integrated delivery system and has already been described, so will not be described further here.

Vertically integrated system

A term that, if used at all, usually refers to an IDS that also offers a health plan. The system may own and operate the plan itself or it may be a partnership or joint venture with an existing payer.

9. What are the broad categories of ancillary services? (know examples from the charts) Examples of Ambulatory Facilities in A Network General ambulatory surgical centers

Birthing centers

Single-Specialty ambulatory surgical centers

Infusion centers for chemotherapy, specialty drug infusion, and the like

Observation centers

Diagnostic imaging centers

Endoscopy centers

Community health centers (not including offices of primary care providers)

Lithotripsy centers

Hospice

Surgical recovery centers

Burn and wound management centers

Radiation oncology centers

Urgent care centers

Pain management centers

Retail health clinics or convenient care clinics

Women’s health centers

Occupational health centers

10. Recognize examples of diagnostic and therapeutic ancillary services. ● Examples of Diagnostic Ancillary Services ○ Laboratory; ○ Specialized laboratory such as genetic testing; ○ Imaging, such as routine radiology (X-rays), nuclear imaging, computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and the like; ○ Electrocardiography; and ○ Any other types of outpatient diagnostic testing services ● Examples of Therapeutic Ancillary Services* ○ Home care; ○ Generalized rehabilitation and habilitation; ○ Focused rehabilitation such as cardiac or post-stroke rehabilitation; ○ Physical therapy (PT); ○ Occupational therapy (OT); ○ Speech therapy; ○ Suppliers of vendors of durable medical equipment (DME) and medical supplies, and ○ Any other types of outpatient therapeutic services

11. Define: ● Physician-Hospital Organization○ Made up of hospital and its staff ○ All admitting physicians vs. smaller group ○ IPA may make up “Physician” portion ○ Negotiate with payers ○ Providers may still contract directly with payer ■ Relatively weak structure ■ Messenger model vs. Actively managed

●

● ●

○ On the decline Management Services Organization○ Physicians■ May be independent, and/or ■ May own assets only of physician practice and/or ■ May belong to groups owned and operated by MSO ○ Often includes hospitals, but not always ○ Provide additional services beyond negotiation, e.g.■ Office support ■ Medical management ■ Billing and connection ■ IT ○ Payer contracting- payer contracts with MSO, vs. payer contracts directly with providers ○ May or may no accept risk Patient-Centered Medical Homes○ Accountable Care Organization○ ACO is a mechanism used to pay a type of provider organization in traditional FFS Medicare, and only traditional FFS Medicare, under the Medicare Shared Savings Program ○ Examples of eligible organizations for Medicare include: ■ Physicians and professionals in group practice arrangements ■ Networks of individual practices of physicians and other professionals ■ Joint ventures/partnerships of hospitals and physicians and professionals ■ Hospitals employing physicians and professionals ○ Commercial ACOs are meant to more or less do the same thing, but there are no rules or requirements

12. Do payers typically credentialing of Facilities? If not, how do they assure compliance?

13. What is the federal DataBank? 14. What types of organizations may conduct primary verification of a physician’s credentials?

15. Identify common form of IDS

CHAPTER 41. What is the Agent-Principle Problem?

The economic incentives of the principal and of the principal’s agent are not aligned 2. What is cost? 1. Total cost of the type of healthcare being measured (cost= price x volume) 2. Cost only cost to the party paying for service 3. Revenue to the party providing the service ● One party’s cost center is another party’s revenue center ● ***** it is NOT reimbursement, it’s a PAYMENT 3. What is the difference between payment and reimbursement? ● Reimbursement- what you get when you submit your travel expenses to your employer ○ Everyone is reimbursed in the same way ○ Its a term implying fairness and equity- righteous, good, true, and moral ○ Aside from padding, reimbursement policies do not drive behavior ● Payment- it's what you get when you cash your paychec...