OMI midterm Exam Actual Questions And Correct Detailed Answers.
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Grado
OMI.
Institución
OMI.
HCFA - correct answer Health Care Financing Administration
administers Medicare program; to handle great number of claims HCFA contracted with insurance companies for claims management, became fiscal intermediaries
cost reimbursement: more care=more reven...
HCFA - correct answer Health Care Financing Administration
administers Medicare program; to handle great number of claims HCFA contracted with insurance
companies for claims management, became fiscal intermediaries
cost reimbursement: more care=more revenue; payer totally responsible/at risk for cost of care
PPS - correct answer Prospective Payment System
uses the pt primary diagnosis to categorize them into DRGs; if the provider can get the pt better in a
shorter amt of time compared to DRG rate then the provider makes money (loses money if longer than
DRG)
DRG - correct answer Diagnosis Related Group
DRG rate is pre-set regardless of the cost incurred caring for the patient
Daily Rates - correct answer per diem rates
providers are paid a fixed rate per day of care
Capitated Payments - correct answer Provider contracts with a health plan to
provide all of a specific type of care to a specific group of people in return for an agreed upon payment
Provider assumes full financial responsibility/risk
Provider has financial incentive to control the amt of service provided
,Managed Care - correct answer comprehensive approach to healthcare; planning
and pt care; pt and provider education; monitoring care quality; cost control
patient gives up exclusive rights to choose healthcare providers: the provider loses its exclusive rights as
decision makers (FINANCIAL RISK IS SHARED)
network of providers contracted with a managed health insurance plan to provider services to members
do not choose PCP and can refer themselves to specialists
not required to stay in network but financial incentive to do so
may require members to meet a deductible before paying and have larger co-pays than HMOs
members accept discounted rates, comply with preauthorization and utilization review
PPO members get more volume business
POS - correct answer Point of Service Organization
hybrid of PPO + HMO
designated PCP
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