Healthcare Systems - Eppp Knowledge

1. What is the term for a patient's fixed amount paid at the time of each visit or prescription?

   Copayment. This fixed fee shares costs with patients, discouraging overutilization and helping insurers manage overall healthcare spending.

2. A plan requires prior authorization for neuropsychological testing; what must you obtain before testing?

   Insurer authorization approval. Obtaining approval ensures compliance with plan requirements, facilitating reimbursement and avoiding denial of coverage for the service.

3. Which care approach emphasizes brief, structured, evidence-based treatment to reduce costs and improve access?

   Stepped care. This model starts with low-intensity interventions and escalates as needed, optimizing resource allocation and enhancing treatment accessibility.

4. Which documentation standard requires that services be reasonable and necessary for diagnosis or treatment?

   Medical necessity. This criterion ensures reimbursement only for services that align with accepted standards, preventing unnecessary or ineffective treatments.

5. Which reimbursement model pays a fixed amount per patient per time period regardless of services?

   Capitation. This model provides a fixed payment per patient, incentivizing providers to manage care efficiently and prevent unnecessary services to control costs.

6. Identify the most cost-effective intervention type for mild depression when clinically appropriate.

   Brief, evidence-based psychotherapy (e.g., CBT). Short-term, targeted therapies like CBT efficiently address symptoms with strong evidence, minimizing sessions and associated costs.

7. A client cannot afford weekly sessions; which scheduling change best aligns with cost constraints?

   Lower-frequency sessions with structured self-management supports. Reducing session frequency with self-help tools extends care affordability, maintaining progress while aligning with economic limitations.

8. In stepped care, what is the usual first-line intensity level when risk is low and impairment is mild?

   Lowest effective intensity (least restrictive level). Beginning with minimal intervention conserves resources and aligns with economic principles by matching treatment intensity to patient needs.

9. Which arrangement restricts coverage to contracted clinicians and usually costs less than out-of-network care?

   In-network coverage (provider network). Contracted providers offer discounted rates, reducing patient costs and steering utilization toward cost-effective network options.

10. What is the term for insurer review of medical necessity after services are delivered?

    Utilization review. This retrospective evaluation assesses whether provided services were appropriate and necessary, aiding in cost control and quality assurance.

11. What is the term for directing patients to lower-cost settings when clinically appropriate?

    Site-of-care optimization. This strategy reduces expenses by shifting care to less resource-intensive environments without compromising clinical outcomes.

12. What is the reimbursement model in which each service is billed and paid separately?

    Fee-for-service. Providers are reimbursed for each individual procedure or visit, which can encourage higher service volume but may increase overall healthcare expenditures.

13. Which service delivery method most directly reduces travel and facility costs while maintaining access?

    Telehealth (telepsychology). Remote delivery eliminates overhead for physical spaces and transportation, broadening reach while preserving therapeutic efficacy.

14. What is the term for the amount a patient must pay out-of-pocket before insurance begins paying?

    Deductible. This threshold promotes cost-sharing, ensuring patients contribute before coverage activates to control premium costs for insurers.

15. What is the term for the percentage of allowed charges the patient pays after meeting the deductible?

    Coinsurance. This percentage-based sharing after the deductible encourages prudent use of services while distributing financial responsibility.

16. What is the term for insurer review requiring approval before providing a service?

    Prior authorization (preauthorization). This process ensures services are medically necessary and cost-effective before delivery, helping insurers manage utilization and expenses.

17. What is the term for the maximum yearly out-of-pocket amount after which the plan pays $100\%$?

    Out-of-pocket maximum. This cap protects patients from excessive costs, after which full coverage applies, balancing affordability with insurer risk management.

18. Which intervention format typically maximizes reach and reduces per-patient cost for a common problem?

    Group therapy. This format allows multiple patients to receive care simultaneously, lowering provider time per individual and enhancing scalability.

19. Which payment model ties reimbursement to quality metrics and outcomes rather than volume of services?

    Value-based payment. This approach rewards efficient, high-quality care by linking payments to performance measures, promoting better outcomes and cost savings.

20. What is the term for a fixed payment covering all services for an episode of care over a time window?

    Bundled payment (episode-based payment). This method encourages coordinated care and efficiency by providing a single payment for all services related to a specific condition or procedure.

21. What is the term for receiving covered services from noncontracted clinicians at higher patient cost?

    Out-of-network care. Noncontracted providers lack negotiated rates, leading to higher patient expenses and incentivizing use of in-network services.

22. Which managed care mechanism requires a primary care clinician to authorize specialty referrals?

    Gatekeeping. This system controls access to specialists, ensuring primary care coordination to optimize resource use and reduce unnecessary referrals.

23. What is the term for insurer limits on covered visits, sessions, or total dollars for care?

    Benefit limits (coverage limits). Insurers impose these restrictions to control costs by capping the extent of coverage for specific treatments or services within a policy period.

24. What is the best term for billing two payers for the same service or billing for a service not provided?

    Fraud (e.g., double billing or phantom billing). These practices involve intentional deception for financial gain, undermining system trust and leading to legal and financial penalties.

25. What is the term for using a diagnosis code primarily to obtain payment when it is not clinically accurate?

    Upcoding (fraudulent miscoding). This unethical practice inflates reimbursement by misrepresenting the patient's condition, violating billing integrity and increasing costs.

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