2024 CRCR Study Guide 1 A+ Rated Guide | Questions and Answers (Solved)

2024 CRCR Study Guide 1 A+ Rated Guide | Questions and Answers (Solved) 1. Health Maintenance Organization (HMO): Answer: Ensures comprehensive healthmaintenance and treatment services for an enrolled group of persons based ona monthly fee. The plan will provide the beneficiary with a list of physicians fromwhich they may choose as their Primary Care Physician (PCP).The beneficiary must contact their PCP to coordinate their care.The PCP will provide the beneficiarywith a referral to a specialist or obtain precert for non-emergent care. This type of insurance only covers approved services provided by HMO providers. If the patientgoes outside the HMO, the patient is liable for the total charges. 2. Preferred Provider Organization (PPO) Answer: This plan isthe closest to an indemnityplan.The employer and the health insurance carrier contract to purchase health careservices from a selected group of participating providers. These providers agree to follow the utilization management and other procedures that are implemented by the PPO and agree to accept the PPO reimbursement structure and payment levels.With this type of plan, the beneficiary may choose to use a non-PPO provider but will have higher coinsurances and/or deductibles. 3. Silent PPO's Answer: A scheme where insurers that don't offer PPO policies apply the contracted PPO discounted rate to the patient's bills that are not part of the PPO network. These payers obtain the database of the preferred provider rates, usually from a broker.These appear as legitimate discounts on the remittance advice (R/A). See page 3 of this section for additional information. 4. Point of Service (POS) Answer: An HMO that offers indemnity type options.The PrimaryCare Physician (PCP) usually make referrals to other providers within the plan.Butwith the POS plan, the beneficiary may self-refer themselves outside the plan and still have some coverage.If the PCP refers outside the network, the plan pays all ormost of the bill. If the beneficiary wants to use a provider outside the network and the service is a covered one, the beneficiary will have higher out of pocket liability 5. Exclusive Provider Organization (EPO) Answer: This type of plan is similar to the PPObut unlike PPO's, they limit their beneficiariesto participating providers.Beneficiariesare required to receive all their care from providers participating in the EPO