Chapter 11: The Blue Plans, Private Insurance, and Managed Care Plans

Insurance Handbook for the Medical Office Fordney Chapter 11: The Blue Plans, Private Insurance, and Managed Care Plans
In times past, physicians in private practice billed indemnity insurance plans and professional services were reimbursed on a fee for service basis.
The HMO Act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance.
Medicare-eligible patients are not involved with HMOs or prepaid health plans.
In a staff model HMO, physicians are hired directly by the health plan that pays their salary.
Exclusive provider organizations (EPOs) are regulated by the federal government.
In a point-of service (POS) program, members may choose to use a non-program provider at any time.
The term "turfing" means to transfer the sickest high-cost patients to other physicians to that the provider appears as a low utilizer.
If a primary care physician sends a patient to a specialist for consultation and the specialist is not in the managed care plan, the specialist may bill the primary care physician for payment.
In certain managed care plans there is an incentive for the gatekeeper to limit patient referrals to specialists.
Managed care plans allow laboratory tests to be performed at any facility the patient chooses.
Managed care plans never require a CMS-1500 claim form to be completed and submitted.
A copayment in a managed care plan is usually a fixed dollar amount (predetermined fee).
Kaiser Permanente's medical plan is a closed panel program, which means...
b) it limits the patient's choice of personal physicians
When an HMO is paid a fixed amount for each patient served without considering the actual number or nature of services provided to each person, this is known as...
b) capitation
What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care?
a) Foundation for medical care
An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is call a/an
c) preferred provider organization (PPO)
A program that offers a combination of HMO-style cost management and PPO-style freedom of choice is a/an...
a) point of service (POS) plan
Practitioners in an HMO program may come under peer review by a professional group called a...
c) quality improvement organization
When a physician sees a patient more than is medically necessary, it is called
c) churning
What is the correct procedure to collect a copayment on a managed care plan?
d) collect the copayment when the patient arrives for the office visit