| Question ID 17160 | Arthur Dace, a plan member of the Bloom health plan, tried repeatedly over an extended
period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr.
Dace informally surveyed other Bloom plan members and found that many people were
experiencing similar problems getting an appointment with this particular provider. Mr.
Dace threatened to take legal action against Bloom, alleging that the health plan had
deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making
it difficult for patients to make appointments with Dr. Pyle.
Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR)
method that is quicker and less expensive than litigation. Under this ADR method, both
Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who
issued a decision that Bloom's utilization management practices in this case did not
constitute a form of abuse. The panel's decision is legally binding on both parties.
Different types of compensation arrangements in managed care plans, from fee-for-service
(FFS) arrangements to capitation arrangements, lead to different types of fraud and abuse.
From the answer choices below, select the response that identifies the form of abuse in
which Bloom is allegedly engaging, according to Mr. Dace's complaint, and whether this
form of abuse is more likely to occur in FFS compensation arrangements or in capitation
arrangements.
|