PHLT 313 Exam 3 |245 Questions and Answers(A+ Solution guide)

MCOs manage - - Financing - Insurance - Delivery - Payment MCOs exercise formal control over the utilization of - Health Care Services The most common methods used for reimbursing providers are: - - Capitation - Discounted fees - Salaries Capitation - - The provider is paid a fixed monthly sum per enrollee - Often called a per member, per month (PMPM) payment Discounted Fees - - A modified form of fee-for-service - Discounts are offered in exchange for a certain volume of business Salaries - Generally combined with bonuses for efficiency Accreditation measures - Performance Accreditation and Quality Organizations - - National Committee for Quality Assurance (NCQA) - The Centers for Medicare and Medicaid Services (CMS) Early 1900s (Evolution and Growth of Managed Care) - Railroad, mining, and lumber companies1929 (Evolution and Growth of Managed Care) - - First private health insurance plan - Baylor University Hospital - Provided teachers with a certain number of hospital stays 1940s (Evolution and Growth of Managed Care) - Large health plans emerged in the US 1973 (Evolution and Growth of Managed Care) - The Health Maintenance Organization Act 1980s (Evolution and Growth of Managed Care) - - Slow growth, but health care costs continued to rise - Creation of other forms of managed care Managed Care today is... - Different than the original form Managed Care 1990s - - Limited number of providers - Control over utilization and limits on reimbursement Managed Care compromise today - - Utilization management was relaxed - Multiple reimbursement method - Increase provider choice 3 Main Types of Utilization Controls - - Expert evaluation - Determination of least expensive service - Review the course of medical treatmentGatekeeping - - Commonly used by HMOs - Primary Care Provider (PCP) coordinate all health services - Emphasizes preventative care, routine physical examinations, and other primary care services - Make referral for specialty services Utilization Review - Evaluates services provided to make sure patient is receiving adequate care with little waste 3 Types of Utilization Control Methods - - Prospective - Concurrent - Retrospective Prospective Utilization Review - Review of course of treatment before the care is actually delivered Concurrent Utilization Review - Review of course of treatment during the health care utilization