Managed Care Flashcards
What is the purpose of managed care in the healthcare system?
A) To increase healthcare costs and reduce quality of care
B) To improve the quality and accessibility of healthcare while containing costs
C) To limit patient access to healthcare services
D) To promote unregulated healthcare practices
B) To improve the quality and accessibility of healthcare while containing costs
What is the characteristic of risk-based plans in Medicare managed care programs?
A) They provide reimbursement based on “fair expenses”
B) They receive a set monthly prepayment per beneficiary
C) They offer a mix of risk- and cost-based policies
D) They prioritize cost containment over quality of care
B) They receive a set monthly prepayment per beneficiary
How are cost-based plans in Medicare managed care programs typically reimbursed?
A) Based on a set monthly prepayment per beneficiary
B) Through a mix of risk- and cost-based policies
C) By receiving reimbursement for their “fair expenses”
D) By prioritizing cost containment over quality of care
C) By receiving reimbursement for their “fair expenses”
How are healthcare providers typically paid for the medical services they provide?
A) Through a system of reimbursement
B) By receiving direct payments from patients
C) Through grants and donations
D) By billing insurance companies for services rendered
A) Through a system of reimbursement (Healthcare reimbursement)
True or False: Healthcare providers are paid by insurance or government payers through a system of reimbursement.
True
What is the coverage expansion of PhilHealth in the Philippines after the implementation of the Universal Healthcare Act?
A) Free medical consultations and laboratory tests
B) Free medication and hospitalization
C) Free dental care and vision services
D) Free mental health services and rehabilitation
A) Free medical consultations and laboratory tests
is largely financed through a tax-based budgeting system, where health services are delivered by government facilities run by the National & local governments.
PUBLIC HEALTHCARE/PRIVATE HEALTHCARE
PUBLIC HEALTHCARE
consisting of for profit & non-profit health care providers, is
largely market-oriented where health care is generally paid for through user fees at the point of service (Dept. of Health, 2005)
PUBLIC HEALTHCARE/PRIVATE HEALTHCARE
PRIVATE HEALTHCARE
Four main sources of financing:
National and local government,
Insurance (government and private),
User fees/out of pocket and
Donors
This procedure, either during the evaluation or as a review after the fact, can detect potential issues related to prescription drugs, such as drug interactions, repeating the
same drugs, allergic reactions, incorrect dosage, and unsuitable treatment.
Monitoring Programs
Prior Authorization Programs
Quality Assurance Programs
Drug Utilization Review Programs
Fraud, Waste and, Abuse Programs
Drug Utilization Review Programs
A process of authorization that promotes the correct utilization of medicines and discourages the inappropriate prescribing of medications. The aim of these program is to guarantee that patients obtain the suitable drugs that will yield the most effective clinical results with minimum expenses
Monitoring Programs
Prior Authorization Programs
Quality Assurance Programs
Drug Utilization Review Programs
Fraud, Waste and, Abuse Programs
Prior Authorization Programs
Some medications require lab- based monitoring or genomic testing .These programs ensure that medications are: Prescribed safely, Used appropriately, Patients receive the best possible outcome.
Monitoring Programs
Prior Authorization Programs
Quality Assurance Programs
Drug Utilization Review Programs
Fraud, Waste and, Abuse Programs
Monitoring Programs
Programs that review key drug classes, monitoring for patterns of inappropriate use.
Monitoring Programs
Prior Authorization Programs
Quality Assurance Programs
Drug Utilization Review Programs
Fraud, Waste and, Abuse Programs
Fraud, Waste and, Abuse Programs
Standard of care programs that enhance patient safety, improve the ways in which patients use medications, and ensure delivery of the highest quality and most current treatment options.
Monitoring Programs
Prior Authorization Programs
Quality Assurance Programs
Drug Utilization Review Programs
Fraud, Waste and, Abuse Programs
Quality Assurance Programs
Establishing, standardizing, and enhancing systems to evaluate coverage rejections, including denials of coverage for medical services patients would like to obtain or reimbursement for services already received, has been a primary focus of patient protection initiatives. There is, however, little information available about the characteristics of managed care organization coverage denials and what transpires in such cases within health plans’ reconsideration, or “appeals,” processes
PATIENT CASE STUDIES
