Under the compensation arrangement that the Falcon Health Plan has with some of its providers, Falcon holds back 10% of the negotiated payments to these providers in order to offset or pay for any claims that exceed the budgeted costs for referral or hospital services. If the providers keep costs within the budgeted amount, Falcon distributes to them the entire amount of money held back. This way of motivating providers to control costs while providing high-quality, appropriate care is known as a:
A provider group purchased from an insurer individual stop-loss coverage for primary and specialty care services with an $8,000 attachment point and 10% coinsurance. If the group's accrued cost for the primary and specialty care treatment of one patient is $10,000, then the amount that the insurer would be responsible for reimbursing the provider group for these costs is:
The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:
In 1996, the NAIC adopted a standard for health plan coverage of emergency services. This standard is based on a concept known as the:
Medicaid beneficiaries pose a challenge for health plans attempting to establish Medicaid provider networks. Compared to membership in commercial health plans, Medicaid enrollees typically
The provider contract that Dr. Lorena Chau has with the Fiesta Health Plan includes an evergreen clause. The purpose of this clause is to:
Since 1981, states have had the option to experiment with new approaches to their Medicaid programs under the “freedom of choice” waivers. Under one such waiver, a Section 1915(b) waiver, states are allowed to
Prior to the enactment of the Balanced Budget Act (BBA) of 1997, payment for Medicare-covered primary and acute care services was based on the adjusted average per capita cost (AAPCC). The AAPCC is defined as the
The following statement(s) can correctly be made about financial arrangements between health plans and emergency departments of hospitals:
The Zephyr Health Plan identifies members for whom subacute care might be an appropriate treatment option. The following individuals are members of Zephyr:
Selena Tovar, an oncology patient who requires radiation oncology services, chemotherapy, and rehabilitation.
Dwight Borg, who is in excellent health except that he currently has sinusitis.
Timothy O'Shea, who is beginning his recovery from brain injuries caused by a stroke.
Subacute care most likely could be an appropriate option for:
