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Flashcards in Managed Care Deck (36)
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1

Indemnity (FFS) plans:

Use FFS payment model
Most expensive plans (premiums) for employers
Most insurers used a deductible
Most insurers used co-insurance

2

Type of payments:

PPO
HMO
Staff model HMO

3

PPO

Preferred Provider Organizations
Still had deductible & co-insurance

4

How is a PPO different from indemnity?

Restricted network (provider panel)
Co-insurance tied to allowable, not billed amount
Lower premiums than indemnity plans
Introduced Utilization Review (UR)

5

What model is used in a PPO?

Discounted Fee-For-Service (DFFS) as primary payment model

6

PPO plan:

Secure a 20-50+% discount from providers

7

Goal of PPO plan:

pass along that 20-50% reduction to employers via lower premiums

8

Why didn't PPO plans work to pass reduction to employers?

Providers increased their prices
Providers saw more patients (increased demand)
Providers did more procedures (increased volume)

9

Old PPO model:

PPO paid 80-90% of the discounted rate after deductible was met
Patient paid 10-20% of what provider billed

10

PPO model now:

Patient pays:
Copay (if applicable)
Co-insurance based on the allowable
PPO pays what is left to meet allowable after deductible is met

11

Utilization review:

Decisions made based on restrospective review of documentation
To pay or not to pay

12

Who performs UR?

Clerks
Nurses
Social workers
Not many PTs perform UR

13

How is HMO different from PPO

Smaller, more restricted, provider network than PPOs
Gatekeeper role for primary care physicians
Capitation for primary care physicians
Withholds
Copays by patients BEFORE services
No deductibles
Pre-authorization by insurer and/or PCP for non-PCP services
Transfer of risk to providers, primarily PCPs

14

Who act as gatekeepers in a HMO?

PCPs

15

How are PCPs paid in a HMO?

capitated rate on a monthly basis that is not tied to how many services are provided

16

What does a copay serve as?

A copay serves as a disincentive for the patient to receive healthcare services since they have to pay it up front versus 2-4 months after the service is provided

17

Withholds:

part of PMPM payment not given to PCP depending on goals
Withholds are returned to the PCP(s) only if those goals are met.

If goals are NOT met, then HMO keeps the withhold money

18

Who are HMOs popular with?

employers
insurers

19

Why would employers like HMOs?

reduced premium growth

20

Why would insurers like HMOs?

reduced growth in healthcare expenditures

21

Why do providers dislike HMOs?

Made the providers the “bad guy”
Created perverse incentives with capitation

22

Why would consumers like HMOs?

low premium and OOP expenses

23

Why would consumers dislike HMOs?

they restricted/denied access to specialists

24

Staff model HMO:

Insurance company owns all entities from the insurer to the providers
Provides the most control over healthcare delivery
Lowest premiums of the HMO models

25

Group model HMO:

HMO contracts with one large multi-specialty physician group for all of their patients
Physicians do not work for the HMO
Can see patients from other insurers
Premiums higher than staff model

26

Which is the first model to reduce health care spending?

HMO

27

Network HMO

HMO contracts with numerous physician providers
Physicians do not work for the HMO
Physicians can see patients from other insurers
Premiums higher than group model

28

IPA HMO

Independent Practitioner Association (IPA)
Physician practices contract with IPA who then contracts with HMO
Physicians not limited to IPA/HMO patients
Introduces middle man (IPA) that wants cut of premiums
Premiums higher than network HMO

29

POS HMO:

Point of Service
Allows patients to seek care outside of the HMO physician/hospital network
However, patient’s pay higher co-pays and co-insurance for going out of network

30

When does medical cost control increase?

when employee choice decreases