Certified Revenue Cycle Representative (CRCR) Practice Exam

What restriction does a managed care plan impose on the choice of service locations?

1. Annual plan adjustment

2. Site-of-service limitation

3. Deductible application rule

4. Referral requirement

The correct answer is: Site-of-service limitation

A managed care plan typically imposes a restriction known as site-of-service limitation. This means that the plan will designate specific facilities or locations where services can be received in order to manage costs and ensure quality of care. By limiting the choice of service locations, managed care plans can negotiate better rates with providers, streamline administrative processes, and encourage the use of efficient care settings. Site-of-service limitations are crucial to how managed care organizations control expenditures while maintaining accountability in patient care. For example, a plan may require that outpatient procedures be performed at designated outpatient surgical centers rather than hospitals, as these settings can offer lower costs for the same procedure due to their efficiency. This approach helps to contain overall healthcare costs and manage risk. While referral requirements involve obtaining approval from a primary care physician before seeing a specialist, and deductible application rules concern how out-of-pocket costs are calculated for services used, these do not specifically address the selection of service locations. Annual plan adjustments pertain more to changes in plan features or premiums, rather than directly impacting where services can be performed. Therefore, site-of-service limitation is the most accurate representation of the restriction imposed by managed care plans on the choice of service locations.