1. For what reason did managed care originally emerge in the early 1900s?

2. What did the HMO Act of 1973 do?

3. What are the rules for patients in closed-access HMOs?

4. What is the principle role of the member services department?

5. What is effective in changing physician behavior?

6. How does traditional insurance compare to managed care?

7. What does traditional insurance cover?

8. Where can closed-access HMOs patients seek care?

9. What common forms of HMOs are there?

10. How can health care be purchased (types of purchasers)?

Define the following:

1. HMO

2. Point of Service

3. Provider

4. Gatekeeper

5. Contract negotiation

6. Discounted fee-for-service

7. Capitation

8. DRG reimbursement

9. Per Diem reimbursement

10. Case rate

11. Community rating by class (CRC)

12. Standard community rating

13. Adjusted community rating (ARC)

14. Experience rating

15. Premium equivalent rating

1. How did the Health Maintenance Organization Act of 1973 help the growth of HMOs?

2. What type of purchasers do MCOs contract with?

3. Name the types of MCOs.

4. What are some common reimbursement mechanisms to physicians?

5. What are some common reimbursement mechanisms to hospitals?

6. What are capitation rates and how do they work? Are they well accepted by providers and consumers?

7. What are the types of per diem rates?

8. What risks are involved with each of the reimbursement mechanisms to the physicians?

9. What are Diagnosis Related Groups?

10. What are some common characteristics of PPOs?

11. What are some commonly recognized models of HMOs?

12. Is capitation a prospective (determined before the service) or retrospective (determined after the service) payment.

13. What is stop-loss insurance? What are the two types?

14. What are the types of HMOs and how does each type arrange its relationship with physicians?

15. What are the basic elements of credentialing?

16. What are carve-outs?

17. Name some performance-based incentives?

18. Why is capitation popular with HMOs?

19. What type of physician reimbursement is based on the value of medical and surgical procedures?

20. Why do MCOs want to capitate specialists?

21. What does the HMO consider in selection of a hospital for network development?

22. What are some components of relative value-based fee schedules?

23. What types of relative value-based fee schedules are there?

24. What is resource-based relative value reimbursement?

25. What happens with re-credentialing?

26. What does an MCO look at during the re-contracting process?

27. How can one improve provider compliance, quality and productivity?

28. What is provider profiling?

29. What does provider profiling allow the MCO to do?

30. In order to properly profile providers, what does the MCO need to take into account?

31. What sources of information are used in provider profiling?

32. Define practice guidelines.

33. How “scientific” are practice guidelines?

34. What do physicians think about practice guidelines?

35. How do you properly deal with handling grievances?

36. What are common steps in a grievance?

37. How do MCOs resolve problems effectively?

38. What is the principle role of the provider relations department?

39. What responsibilities does the claims department have?

40. Describe claims adjudication and payment.