Which of the following INCORRECTLY pairs a tool used by intermediaries with an example of its use?1 pointCase management- an insurance company works with doctors to ensure that a patient receives appropriate follow-up care after returning home from a hospitalization. Utilization review- an insurance company asks for a second physician’s opinion before approving a patient’s surgery. Tiered formulary- an insurance company requires a smaller copayment from patients when they use the drugs preferred by the company, usually generic drugs. Pre-admission review- prior to surgery, an insurance company requires that a patient get approval for a hospital stay following surgery, or else the company will not pay for the hospitalization.
Question
Which of the following INCORRECTLY pairs a tool used by intermediaries with an example of its use?1 pointCase management- an insurance company works with doctors to ensure that a patient receives appropriate follow-up care after returning home from a hospitalization. Utilization review- an insurance company asks for a second physician’s opinion before approving a patient’s surgery. Tiered formulary- an insurance company requires a smaller copayment from patients when they use the drugs preferred by the company, usually generic drugs. Pre-admission review- prior to surgery, an insurance company requires that a patient get approval for a hospital stay following surgery, or else the company will not pay for the hospitalization.
Solution
The question is asking which of the given examples does not correctly match the tool used by intermediaries (such as insurance companies) with its use.
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Case management - This is correctly paired. Case management involves coordinating services for a patient, which can include ensuring appropriate follow-up care after a hospital stay.
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Utilization review - This is also correctly paired. Utilization review involves evaluating the necessity, appropriateness, and efficiency of healthcare services, which can include asking for a second opinion before approving a surgery.
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Tiered formulary - This is correctly paired as well. A tiered formulary is a list of medications covered by an insurance plan, which are divided into tiers based on cost. The lower tiers usually include generic drugs and require smaller copayments.
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Pre-admission review - This is incorrectly paired. Pre-admission review involves reviewing the necessity of a hospital admission before it occurs, not after surgery. Therefore, the insurance company would not require approval for a hospital stay following surgery, but rather before the surgery and subsequent hospital stay.
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