1. List and discuss the three payment-determination bases.
2. Explain the difference between a specific services payment unitcompared to a bundled services payment unit.
3. What are the three major ways that health care providers cancontrol their revenue function?
4. What are the three factors that influence pricing?
5. Why does market share matter to a health care provider?
6. What contract provision will best protect a hospital being paidon a DRG basis for inpatient services from a catastrophicpatient?
7. Why should providers seek whenever possible to minimize healthplan rate differentials?
8. What can a health care provider vary across differentpayers?
9. What is the best way to compare hospital costs?
10. What measure(s) is used directly as one of the means ofdetermining the reasonableness of a hospital’s charges?
11. What are the four major activities of a health plan?
12. Explain coordination of benefits.
13. What does a high deductible health plan with a savings optioninclude?
14. What is a withhold feature for payment to health careproviders?
15. What promotes the growth of Integrated Delivery Systems?
16. Why are capitation plans more common for physicianpayments?
17. The James Clinic is an organization of 100 physicians in avariety of specialties. They recently contracted with PrudentialHealth Plan on a capitated basis to provide all medical services toPrudential's members for the next three years. What would this HMOmodel be defined as?
18. What provision would a medical group include in its contractwith an HMO to receive larger PMPM payments if the HMO members arechronically ill?
19. You are trying to establish a PMPM rate for Primary CarePhysicians. Actuarial estimates project 2,500 visits per 1,000members per year. You have contracted with a Primary Care Medicalgroup at $45.00 per visit with a $5.00 copayment that you willreceive. What PMPM rate should you set?
20. An HMO has a Point of Service (POS) option for its members, butwill pay only 80% of approved charges. If a member goes out ofnetwork for a medical procedure with a charge of $2,000, of which$1,200 is approved, how much must the member pay?
21. A hospital has contracted with an HMO to provide acute careinpatient services for $1,000 per day, subject to a 10% withhold.The proposed budget for inpatient services is based upon expectedutilization of 600 days per 1,000 members at $1,000 per day, or$600,000 per 1,000 members. The hospital risk pool will be splitequally between the hospital and a primary care physician group. Ifonly 450 days per 1,000 members were utilized in the first year,how much would the hospital be paid per 1,000 members?
22. A nursing home contracts with an HMO for skilled nursing careat $2.00 PMPM. If costs are expected to average $120 per day, whatis the maximum utilization of days per 1,000 members that thenursing home can experience before it begins to lose money?