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Reimbursement5

Managed Care

QuestionAnswer
Capitation Method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount for each person enrolled without regard to the actual number or nature of services provided or number of persons served.
Carve-out Contracts that separate out services or populations of patients or clients to decrease risk and costs.
Case Management Coordination of individuals' care over time and across multiple sites and providers, especially in complex and high-cost cases. Goals include continuity of care, cost-effectiveness, quality, and appropriate utilization
Cherry-picking Targeting the enrollment of healthy patients to minimize healthcare costs.
Closed panel Type of health maintenance organization that provides hospitalization and physicians' services through its own staff and facilities (staff or group model)
Community rating Method of determining healthcare premium rates by geographic area rather than by age, health status, or company size.
Cost sharing Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; a cost-control mechanism.
Disease management
Dual eligivle
Enrollee
Episode-of-care reimbursement
Evidence-based clinical practice guidelines
Exclusive provider organization (EPO)
Fee-for-service reimbursement
Formulary
Gatekeeper
Global payment
Group practice model
Created by: Lyn Slough