1) As the office manager of a large practice, you are responsible for facilitating the new employee orientation program. The orientation program includes information about the following managed health care models:

• Exclusive provider organization (EPO)
• Integrated delivery system (IDS)
• Health maintenance organization (HMO)
  • Direct contract model
  • Group model
  • Individual practice association (IPA)
  • Network model
  • Staff model
• Point-of-service plan (POS)
• Preferred provider organization (PPO)
• Triple option plan

Briefly describe each managed health care plan.

2) Health care providers are responsible for documenting and authenticating legible, complete, and timely patient records in accordance with federal regulations and accrediting organization standards. The provider is also responsible for correcting or altering errors in patient record documentation. A patient record documents health care services provided to a patient and includes patient demographic data, documentation to support diagnoses and justify treatment provided, the results of treatment provided, and the plan for future treatment.

A commercial health insurance company reviewed patient records as part of the claims payment process and then denied payment for submitted procedures and services totaling $7,000. The insurance company's denial letter stated that documentation about denied procedures and services were not found in the patient record. What action should the provider's office take?

The coder assigned a CPT code to "x-ray, right femur" and an ICD-10-CM code to "fracture, right humerus." The health insurance company denied reimbursement for the submitted claim due to lack of medical necessity. What action should the provider's office take?

The patient underwent a blood glucose test, and the provider documented "type 2 diabetes mellitus" in the patient record. The coder assigned a CPT code to "blood glucose test" and an ICD-10-CM code to "type 2 diabetes mellitus." The health insurance company reviewed the submitted claim and determined that support of medical necessity was evident. Should the insurance company reimburse the provider for this encounter? If yes, why? If no, why not?