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GBA 1 - Study Guide Exam – 38 Questions and Answers
GBA 1 - Study Guide Exam – 38 Questions and Answers
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GBA 1 - Study Guide Exam – 38 Questionsand Answers
What was the purpose of the Health Maintenance Organization Act of 1973? -
-The 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"
-How did the passage of the Health Maintenance Organization Act of 1973
affect the growth of HMOs? - -The 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? - -PPO 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
-Why didnt many employers realize long-term costs savings with PPO? - -
Because they were primarily discounted fee-for-service arrangements with
little focus on utilization control.
-What steps did PPO companies take to correct this problem? - -Increase the
monitoring of utilization, implementing quality control and surveying
member satisfaction.
-What do opponents of the PPO approach argue is the reason they are more
expensive than HMOs? - -They 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? - -
There 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? - -
Managed 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 - -Is 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 - -1) 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
-Incentive design of PPO plan - -Primary 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 - -The primary objective was cost savings
with preferred benefits equal to the prior plan and nonpreferred benefits
being significantly reduced.
Ex.: 80% preferred expenses. 60% higher deductible.
-Combination approach of PPO Plan - -Some 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 is the key component of the point-of-service plan concept? - -The
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.
-What plan features are often included in POS plan to encourage care within
the network through the PCP? - -1) 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
4) No member claim submission when the PCP renders care or coordinates
care within the network
5) The PCP directs medical care and obtains necessary precertifications for
hospital confinements and referral care.
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