The Method That the Autumn Health Plan Uses for Reimbursing

question 173

Multiple Choice

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline. Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn's PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn's dermatology services fund for the first quarter was $15,000. During the quarter, Autumn's PCPs made 90 referrals, and 20 of these referrals were classified as complicated. Autumn's method of reimbursing specialty providers can best be described as a

• A) Disease-specific arrangement
• B) Contact capitation arrangement
• C) Risk adjustment arrangement
• D) Withhold arrangement

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Definitions:

Paying Wages

The process of compensating employees for their labor, typically calculated by the hour, day, or based on output.

Cash Outflow

Money that is spent or transferred out of a business, reducing its cash balance.

Cash Equivalents

Short-term, highly liquid investments such as Treasury bills, commercial paper, and money market funds, that are made solely for the purpose of generating a return on temporarily idle funds.

Statement of Cash Flows

A financial statement that provides aggregate data regarding all cash inflows a company receives from its ongoing operations and external investment sources, as well as all cash outflows that pay for business activities and investments during a given period.