Network Fundamentals Flashcards

A health plan that contracts with a medical group rather than individual physicians is using which network arrangement?

Answer: Group model HMO

In a group model HMO, the plan contracts with an organized physician group (not individual doctors), and the group collectively provides services to plan members.

What is a 'narrow network' health plan?

Answer: A plan with a limited number of contracted providers to reduce costs

Narrow network plans contract with a smaller, selective group of providers, typically offering lower premiums in exchange for limiting member choice.

When a member receives covered emergency services from an out-of-network provider, the plan is generally required to reimburse at:

Answer: The in-network cost-sharing level (post No Surprises Act)

Under the No Surprises Act, emergency services from out-of-network providers must be reimbursed and cost-shared as if provided in-network, protecting members from excess charges.

Which network contract clause gives a provider the right to receive the same rate increase given to other providers in the network?

Answer: Parity clause

A parity clause ensures that if the payer grants rate increases to other similarly situated providers, the contracted provider will receive the same adjustment.

A 'hold harmless' clause in a provider-payer contract protects:

Answer: The patient from being billed for covered services if the plan fails to pay the provider

A hold harmless clause prevents participating providers from billing patients for covered services in the event of a dispute or non-payment between the provider and the plan.

Continuity of care provisions in managed care contracts primarily protect patients by:

Answer: Allowing members to continue seeing a provider for a transitional period if the provider leaves the network

Continuity of care provisions allow members who are mid-treatment to continue with a departing in-network provider at in-network rates during a defined transition period.

In managed care, a 'silent PPO' arrangement occurs when:

Answer: A payer accesses contracted rates without a direct agreement with the provider

A silent PPO is when a payer or claims re-pricer accesses a provider's discounted contracted rates through a network rental arrangement without the provider's direct knowledge or agreement.