HSM 420 Midterm Exam

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HSM 420 Midterm Exam 
(TCO 1) Describe the preferred provider organization (PPO) model of managed…

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HSM 420 Midterm Exam

HSM 420 Midterm Exam

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(TCO 1) Describe the preferred provider organization (PPO) model of managed care. Why do you feel that this is the dominant form of managed care today?

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In this plan, the patient uses a medical provider under contract with the insurer for an agreed-upon…

(TCO 1) How has the relationship between government and managed care evolved over the years? What factors have driven this changing relationship?

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Over the past two decades, managed care organizations (MCOs) have emerged in the United States. The differences between types of managed care organizations are…

(TCO 2) What is the role of the credentialing committee in a managed care organization? And why is this function so crucial?

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Credentialing refers to the review of a professional provider’s ability to meet the plan’s standards for participation, being board certified…

(TCO 2) Why do managed care organizations have a board of directors? What is the function of the board of directors?

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Managed care has a board of directors to plan and to the shareholders in the event that the plan is for…

(TCO 3) What are the three basic categories of utilization management? Provide a brief description of each category.

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The three primary categories of utilization management are: 1.) Prospective is for elective procedures or services prior to such services being…

(TCO 3) What is meant by “outliers” in hospital reimbursement? How do outlier cases impact reimbursement to a hospital?

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Outlier’s cases refer to extra payment if a patient’s costs exceed certain thresholds. It is less…

(TCO 4) Discuss some key general aspects of physician practice behavior? Include implicit messages from training, and also environmental factors, in your answer.

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As we all know, it takes a long process to be a physician. Thus, physicians are selected for medical school because of certain…

(TCO 4) What is meant by large case management (LCM) under managed care? Provide some specific examples of this type of case management.

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Large case management (LCM) under managed care is a process of identifying plan members with special healthcare needs, developing a…

(TCO 7) What is the purpose of the declarations in managed care contracts?

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The purpose of the declarations in managed care contracts the parties provide answers to a number of “what if” questions. This is simply…

(TCO 7) What is the purpose of hold-harmless and balance-billing clauses in managed care contracts?

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The hold- harmless clause involves the provider agreeing to not pursue a patient for fees in excess of the allowed amount of the…

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