Provider Network

Question 1

Reasons why health plan want to contract with providers (5)

Answer 1

1. ) Obtain favorable pricing (less than full billed amounts)
2. ) Obtain payment terms that result in an underwriting gain
3. ) Get the provider to agree to provide services to the plan’s members
4. ) Meet service area access standards required by the states and Medicare
5. ) Obtain contractual agreement for several clauses, may of which are required by the states and Medicare

Question 2

Basis of minimum access requirements (5)

Answer 2

1. ) Distance or travel time
2. ) Number of providers
3. ) Differ by provider type (PCP vs. Spec)
4. ) Differ by area (rural vs. urban)
5. ) Length of time to get appointment

Question 3

Provider Contractual agreement terms (7)

Answer 3

1. ) Submit claims directly to the plan, not the member
2. ) No balance bill the member for any amount above the agreed upon payment terms
3. ) Hold harmless the member (not bill for any amounts owed by the plan)
4. ) Cooperate with the plan’s utilization management program
5. ) Cooperate with the plan’s quality management program
6. ) Provider allows auditing of clinical and billing data
7. ) Provider agrees to other requirements (i.e. not to discriminate)

Question 4

Reasons for a provider to contract with a payer (6)

Answer 4

1. ) Obtain favorable payment terms
2. ) Ensure inclusion in the provider network of a large plan
3. ) Receive direct and timely payment from the plan
4. ) Steerage of members by the plan to providers
5. ) Rights if there is a dispute regarding claims and payments
6. ) Not lose business or medical staff as a payer steers members to others who are contracted providers

Question 5

Contract Management Systems (CMS) Functions (8)

Answer 5

1. Track provider demographic and credentialing information
2. Track payment rates by provider and plan
3. Update changes in provider
4. Identify network gaps
5. Track provider recruiting efforts
6. Track and report contract changes by provider
7. Indicate upcoming negotiations and re-credentialing
8. Analyze impact of changes to contracting terms

Question 6

PPO vs HMO staffing focus

Answer 6

1. HMO focus on physician to member staffing ratios

2. PPO focus on having sufficient number of providers representing major specialties

Question 7

Advantages of physician assistants/nurse practitioners (NPC) (4)

Answer 7

1. Deliver excellent primary care services
2. Provide more health maintenance and health promotional services
3. Spend more time with patients
4. Manage patients with chronic conditions

Question 8

Types of physicians and other professional providers (5)

Answer 8

1. PCP and SCP - for traditional HMOs, the distinction between this is important b/c PCP is gatekeeper
2. Hospital based physicians - Physicians have exclusive rights to a hospital, so reluctant to contract for any less than full charge.
3. Nonphysician or mid-level practitioners that provider primary care - physician assistants/nurse practitioners.
4. Mental health providers
5. Other types - podiatrist, dentist, orthodontist, optometrists, chiro, physical therapist, nutritionists, accupuncture, home health care

Question 9

Hospital based physicians specialty types (5)

Answer 9

1. radiology
2. anesthesiology
3. pathology
4. emergency medicine
5. hospitalist

Question 10

Mental Health Provider Types (7)

Answer 10

1. Psychiatrist - specializes in mental health and able prescribe rx
2. psychologist - has doctoral degree in psychology and 2 yrs of supervised prof exp
3. Clinical social worker - counselor with master’s degree in social work
4. Licensed prof counselor - has master degree in psychology, counseling or related field
5. Certified alcohol & drug abuse counselor - has specific training in alcohol & drug abuse & provides individual and group counseling
6. Pyschiatric nurse practitioner or nurse psychotherapist - a registered nurse practitioner with special training in psychiatric & mental health nursing
7. Marital and family therapist - counselor with master’s degree & special training in marital and family therapy

Question 11

Individual Physicians Contracting Considerations Advantage (1) and Disadvantage (1)

Answer 11

Advantages
1. Direct relationship with physician

Disadvantages
1. Effort to maintain relationship is large for just one physician

Question 12

Medical Groups Contracting Considerations Advantage (1) and Disadvantage (1)

Answer 12

Advantages
1. Same contracting effort yields a higher number of physicians

Disadvantages
1. If relationship is terminated then there is greater disruption in patient care

Question 13

Independent Practice Associations (IPA) Contracting Considerations Advantage (3) and Disadvantage (2)

Answer 13

Advantages

1. Large number of providers come along with contract
2. May accept more financial risk
3. Some IPAs perform network management, credentialing & medical management

Disadvantages

1. Can hold considerable portion of the delivery system hostage to negotiations
2. Plan’s ability to select and deselect individual physicians is limited

Question 14

Faculty Practice Plans Contracting Considerations Advantage (1) and Disadvantage (2)

Answer 14

Medical groups that are organized around a teaching program

Advantages
1. Provide highly specialized care & add prestige to plan by reputation for quality care

Disadvantages

1. Tend to be less cost effective in their practice styles
2. Not set up for case management so care is not well coordinated

Question 15

Physicians in integrated delivery system (IDS) types (2)

Answer 15

1. Hospital systems that affiliate with private physicians

2. Hospitals that employ physicians - these often have substantial negotiating leverage

Question 16

Patient Centered Medical Homes

Answer 16

Coordinates all care for a group of patients

Question 17

Specialty Management Companies

Answer 17

These focus on managing very specialized services using physicians (e.g. single-specialty case management of neonatal care)

Question 18

Physician Credentialing Application Typical Elements (9)

Answer 18

1. Demographics, licenses, and other identifiers (such as NPI)
2. Education, training, and specialties
3. Practice details - such as services provided and office hours
4. Billing and remittance info
5. Hospital admitting privileges
6. Prof liability insurance
7. Work history and references
8. Disclosure questions - such as suspensions from gov programs or felony convictions
9. Images of supporting documents - such as state license certificate

Question 19

Types of healthcare facilities (13)

Answer 19

1. ) Community based single acute care hospitals - dominant in rural areas, difficult to negotiate b/c little alternative
2. ) Multihospital systems (MHSs) - consolidation has led to most hospitals being part of MHS, which gives them negotiating leverage
3. ) For-profit national hospital companies - have much less local autonomy
4. ) Specialized hospitals - provide care to only certain type of patients (e.g. children’s hosp, psychiatric hosp)
5. ) Physician-owned single-specialty hospitals - restrict to elective procedures within a single specialty, so not equipped to handle emergencies & severe conditions
6. ) Accountable Care Organizations - coordinate care for designated Medicare FFS beneficiaries & participate in shared savings program
7. ) Government hospitals - may be county, state or federal
8. ) Subacute care (skilled or intermediate nursing facilities) - suited for prolonged convalescence or recovery cases. Cost for bed day less than acute-care hospital
9. ) Ambulatory Surgical Centers (ASCs) and procedure centers - equipped to handle only routine cases
10. ) Hospice - health care services provided at end of life, which may be at IP facility, ambulatory facility or no facility
11. ) Retail health clinics - small clinics associated with retail store (Target or Walgreens); provide basic primary care services such as immunizations & preventive screenings
12. ) Urgent care centers - hybrid of low-level ER dept and PCP practice
13. ) Other types of ambulatory facilities - includes centers for birthing, community health, diagnostic imaging, occupational health, women’s health

Question 20

Types of Ancillary Services (4)

Answer 20

1. Diagnostics
2. Therapeutic
3. Pharmacy
4. Ambulance and medical transportation services

Question 21

Types of Diagnostic Services (4)

Answer 21

1. Lab
2. Imaging (such as X-rays and MRIs)
3. Electrocardiography
4. Cardiac testing

Question 22

Types of Therapeutic Services (6)

Answer 22

1. Cardiac rehab
2. Non-cardiac rehab
3. Physical therapy
4. Occupational therapy
5. Speech therapy
6. Other long-term therapeutic services