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OMI midterm Exam Actual Questions And Correct Detailed Answers.
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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...

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  • September 15, 2024
  • 19
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • omi midterm

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  • OMI.
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OMI midterm

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)



consumer pays more of the bill for healthcare



utilization management/care management



provider accountability for performance outcomes



restrictive guidelines for provider participation



Utilization Management/Care management - correct answer primary gate keepers



case management coordinates/controls care



2nd options may be required



pre-authorization required even before care is given



utilization review: concurrent/retrospective



Standardized and best practice guidelines



wellness and prevention activities

, HMO - correct answer Health Maintenance Organization



comprehensive healthcare for prepaid, fixed rate



PCP chosen from a list; PCP must be consulted to see a specialist who must be part of HMO network



stay in network to be covered



typically low or no deductibles but pay a nominal co-pay



PPO - correct answer Preferred Provider Organization



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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