GBA 1 - Study Guide Questions & Answers 100% Correct!!
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GBA 1 - St
Institution
GBA 1 - St
What was the purpose of the Health Maintenance Organization Act of 1973? - ANSWERThe health maintenance organization action of 1973 provided federal initiatives - consisted of federal grants and loans to organizations wishing to investigate the feasibility of "federally qualified HMO"
Why didnt ...
GBA 1 - Study Guide Questions & Answers 100%
Correct!!
What was the purpose of the Health Maintenance Organization Act of 1973? - ANSWERThe health
maintenance organization action of 1973 provided federal initiatives - consisted of federal grants and
loans to organizations wishing to investigate the feasibility of "federally qualified HMO"
Why didnt many employers realize long-term costs savings with PPO? - ANSWERBecause they were
primarily discounted fee-for-service arrangements with little focus on utilization control.
What steps did PPO companies take to correct this problem? - ANSWERIncrease the monitoring of
utilization, implementing quality control and surveying member satisfaction.
How did the passage of the Health Maintenance Organization Act of 1973 affect the growth of
HMOs? - ANSWERThe government began to withdraw its funding during the Reagan administration.
Smaller plans did not survive.
Briefly explain why the preferred provider organization (PPO) concept was developed? - ANSWERPPO
was sponsored by national insurance companies, third party administrators, BCBS plans, and hotel
organizations. PPO gained quick popularity with employers that wanted cost savings but were
unwilling to reduce provider choice as much that required HMOs
What do opponents of the PPO approach argue is the reason they are more expensive than HMOs? -
ANSWERThey argue that PPOs are weak form of managed care with rich benefits, making them more
expensive than HMOs.
Is there a universally accepted and used definition of managed care? - ANSWERThere is no specific
and uniformly accepted definition of the term "managed care"
What is the definition of managed care provided in the text to include the broad range of managed
indemnity plans, HMOs, PPOs, and PO plans? - ANSWERManaged care includes those programs
intended to influence and direct the delivery of health care through: 1) plan design failure 2)
Restricted access to a specified group of preselected providers 3) Utilization management programs
, Define the concept of steerage - ANSWERIs the managed care company's way of directing members
to in-network providers. Commonly accomplished through setting benefit differentials between in-
and out-of-network care between 10%-30%. It is critical to maximize financial results of managed
care.
Utilization Management (UM) prgrams - ANSWER1) Precertification of inpatient admissions
2)Concurrent review of ongoing confinements for medical necessity
3)Discharge planning
4)Precertification for selected outpatient services
5)Second surgical opinion
6)Case management for high-dollar cases
What is the key component of the point-of-service plan concept? - ANSWERThe primary care
physicians (pcp) is the key component of the POS concept, and preferred benefits are available only
for care rendered by or coordinated through the member PCPs. The PCP acts like a gatekeeper to
specialist care. The primary care generally is family practitioner, general practitioner, internist or
pediatrician.
Incentive design of PPO plan - ANSWERPrimary objective was to introduce a managed care plan with
the least amount of employee disruption. It offered members richer preferred benefit while
maintaining existing benefit levels for nonpreferred benefits.
Ex.: 100% for preferred expenses, 80% for standard comprehensive medical plans
Disincentive design of PPO Plan - ANSWERThe primary objective was cost savings with preferred
benefits equal to the prior plan and nonpreferred benefits being significantly reduced.
Combination approach of PPO Plan - ANSWERSome improvement in benefits while at the same time
saving money. Preferred benefits were set at a slightly higher level, for example 90%, and the non
preferred benefits at a lower level, 70%.
What plan features are often included in POS plan to encourage care within the network through the
PCP? - ANSWER1) No deductible and 100% coverage after a small copay.
2)Preventive services when obtained through the member's PCP
3) One routine gynecological exam per year
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