Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:
CMS Medicare + Choice regulations include a provision that allows health plans to deny benefits for any services the health plan objects to on moral or religious grounds. The provision that exempts health plans from providing such services is known as
With regard to the laws and regulations on access and adequacy of provider networks, it can correctly be stated that:
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 statements are about workers' compensation provider networks. Select the answer choice containing the correct statement:
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.
The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:
Dr. Michelle Kubiak has contracted with the Gem Health Plan, a Medicare+Choice health plan, to provide medical services to Gem's enrollees. Gem pays Dr. Kubiak $40 per enrollee per month for providing primary care. Gem also pays her an additional $10 per enrollee per month if the cost of referral services falls below a targeted level. This information indicates that, according to the substantial financial risk formula, Dr. Kubiak's referral risk under this contract is equal to:
Reimbursement for prescription drugs and services in a third-party prescription drug plan typically follows one of two approaches: a reimbursement approach or a service approach. One true statement about these approaches is that:
Health plans can often reduce workers’ compensation costs by incorporating 24-hour coverage into their workers’ compensations programs. Twenty-four-hour coverage reduces costs by
The BBA of 1997 specifies the ways in which a Medicare+Choice plan can establish and use provider networks. A Medicare+Choice plan that operates as a private fee for service (PFFS) plan is allowed to
