- (TCO 1)Why were the first proto-HMOs formed in America? What were the original driving factors in the HMO movement?
- (TCO 1)What is meant by indemnity coverage, and how does it change in managed indemnity?
- (TCO 2) What is the role of the executive director in a managed care organization? Could you see yourself practicing in this position at some point in your career?Why or why not?
- (TCO 2) What is the role of the Peer Review Committee in a managed care organization? And why is this function so crucial?
- (TCO 3) Describe the calculation of capitated payments. How are these rates determined in managed care organizations?
- (TCO 3) Describe the use of evidence-based clinical criteria in managed care. Why is this process so important in managed care today?
- (TCO 4) What is meant by pattern review under managed care? Why do payers conduct pattern review, and what kinds of things might they identify during such reviews?
- (TCO 4) Discuss some key general aspects of physician practice behavior? Include implicit messages from training, and also environmental factors, in your answer.
- (TCO 7) What is the purpose of hold-harmless and balance-billing clauses in managed care contracts?
- (TCO 7) What is typically covered under “term, suspension, and termination” of a managed care contract?