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Managed Health Care

ch. 3

Term	Definition
accreditation	voluntary process that a healthcare facility or organization (e.g., hospital or managed care plan) undergores to demonstrate that ithas met standards beyond those required.
adverse selection	converting n=memebers who are sicker than the general population.
Amendment to the HMO Act of 1973	professional association established to provide a national certificaton and credentialing process, to supportthe national and local membership by providing educational products and opportunities to networks, and to increase and promote national recogniti
cafeteria plan	also called triple plan option provdies different health benefits plans and extra coverage options through an insurer or third-party administrator.
capitation	provdier accepts preestablished payments for providing healthcare services to enrollees over a periodoftime (usually one year).
case management	development of patient care plans to coordinate and provide care for complicated cases in a cost-effective manner.
case manager	submits written confirmation, authorizing treatment, to the provider.
closed-panel HMO	claims for which all processing, including appeals, has been completed.
competitive medical plan (CMP0	an HMO that meets fedral, eligibility requirements for a Medicare risk contract, but is not licenses as a federallyh qualified plan.
concurrent review	review for mecdial necessity of tests and procedures ordered during an inpatitent hospitalization.
consumer-directed health plan (CDHP)	(consumer-driven health plan) healthcare plan that encourage individuals to locate the best health care at the lowest possible price, with the goal of holding down costs.
customized sub-capitation plan (CSCP)	managed care plan in which healthcare expenses are funded by insurance coverage; teh individual selects one of each tuype of provider to create a customizedc network and pays the resulting customized insurance premium; each provider is paid a fixed amount
direct contract model HMO	contracted healthcare services delivered to subscribers by individual physicians in the community.
discharge planning	involves arranging appropriats healthcare services for the discharged patients (e.g., home health care).
enrollees	(converted lives) employees and dependents who join a managed cae plan; known as beneficiaries in private insurance plans.
exclusive provider organization (EPO)	managed care plan that provides benefits to subscribers if they receive services from network providers.
external quality review organization (EQRO)	resonsible for reviewing health care provided by managed care organizations.
federally qualified HMO	certified to provide healthcare services to Medicate and Medicaid enrollees.
fee-for-service	reimbursement methodology that increases payment if the healthcare service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services (e.g., generic prescription medication).
flexible benefit plan	(cafeteria plan and triple option plan)
flexible spending account (FSA)	tax-exempt account offered by employers with any number of employees, which individuals use to pay healthcare bills; participants enroll in a relatively inexpensive, high-deductible insurance plan, and a tax-deductible savings account is open to cover cur
gag clause	prevents providers from discussing all treatment options with patients; whether or not the plan would provide reimbursement for services.
gatekeeper	primary care provider for essential healthcare services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists.
groud model HMO	contracted healthcare services delivered to subscribers by participating physicians who are members of an independent multispecialty group practice.
group practice without walls (GPWW)	contract that allows physicians to maintani their own offices and share servces (e.g., appotintment scheduling and billing).
Healthcare Effectiveness Data Information Set (HEDIS)	created standards to assess managed-care systems using data elements that are collected, evaluated, and published to compare the performance of managed healthcare plans.
healthcare reimbursement account (HCRA)	tax-exempt account used to pay for healthcare expenses; individual decides, in advance, how much money to deposit in an HCRA (and unused funds are lost).
health maintenance organization (HMO)	responsible for providing healthcare services to subscribes in a given geopgraphical area for a fixed fee.
Health Maintenenace Organization Assistance Act of 1973	authorized grantsand loans to develop HMOs under private sponsorship; defined a federally qualified HMO as one that has applied for, and met, federal standards established n the HMO Act of 1973; required most employers with more than 25 employees to offer
health reimbursement arrangement (HRA)	tax-exempt accounts offered by employers with more than 50 employeel; individuals use HRAs to pay health-care bills, HRAs must be used for qualified healthcare expenses, require enrollment in a high-deductible insurance policy, and can accumulate unspent
health savings account (HSA)	(flexible spending)tax-exempt account offered by employees wiht any number of employees, which indivduals use to pay healthcare bills, participants enroll in a relatively inexpensive, high-deductible insurance plan, and a tax-deductible servings account
health savings security account (HSSA)	(flexible spending account) tax-exempt account offered by employers with any number of employees, which individuals use to pay healthcare bills; participants enroll in a relatively inexpensive, high-deductible insurance plan, and a tax-deductible savings
independent practice association (IPA) HMO	also called individual practice association (IPA); type of HMO where contracted health services are delivered to subscribers by physicians who remain in theri independent office settings.
individual practice association (IPA) HMO	(independent practice association) type of HMO where contracterd health services are delivered to subscribers by physicians who remain in their independent office settings.
integrated provider organization (IPO)	manages the delivery of healthcare services offered by hospitals, physicians employed by the IPO, and other healthcare organizations (e.g., an ambulatory surgery clinic and a nurinsg facility).
legislation	laws.
manage care organization(MCO)	responsible for the health of a grouyp of enrollees; can be a health plan, hospital, physician group, or health systems.
managed healthcare organization (managed care)	combines healthcare delivery with the financing of services provided.
management service organization (MSO0	usually owned by physicians or a hospital and provides practice management (administrative and support) services to individual physician practices.
mandates	laws.
medical foundation	nonprofit organizton that contracts wiht and acquires the clinical and business assets of physician practices; teh foundatoin is assigned a provider number and amnages the practice's business.
medical savings account (MSA)	tax-exampt trust or custodial account established for the purpose of paying medical expenses in conjunction with high-deductible health plan; allows indivudals to withdraw tax-free funds for healthcare expenses, which are not covered by a qualifying high
Medicare+Choice	(Medicare Advantage) incldues managed care plans and private fee-for-service plans, which provides care under contract to Medicare and may include such benefits as coordination of care, redutions in out-of-pocket expenses, and prescription drugs.
Medicare risk program	federally qualified HMOs andcompetitive medical plans (CMPs) that most specfied Medicare requirements provide Medicare-covered services under contract.
National Committee for Quality Assurance (NCQA)	a private, not-for-private organization that assesses the quality manage care plans in the United States and releases the data to the public for its consideration when selecting a managed care plan.
network model HMO	contracted healthcare servies provided to subscribers by two or more physicians multispecialty.
network provider	phsycian or healthcare facility under contract to the managed care plan.
Office of Managed Care	CMS agency that facilitates innovation and competition among Medicare HMOs.
open-panel HMO	health care provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO.
physician incentive plan	requires managed care plans that contract with Medicare or Medicaid to disclose information about physician incentives plans to CMS or state Medicaid agencies befoe a new or renewed contract receives final approval.
physician incentives	include payments mede directly or indirectly to healthcare providers to serve as encouragement to reduce or limit services (e.g., discharge an inpatient from the hospital more quickly) to save money for the managed care final approval.
physician-hospital organization (PHO)	owned by hospital(s) and physician groyps tht obtainn managed care plan contracts; physicians maintain their own practices and provide healthcare services to plan members.
point-of-service plan (POS)	delivers healthcare services using both managed care network and traditional indemnity coverage so patients can seek care outside the managed care network.
preadmission certification (PAC0	review for medical necessity of inpatient care prior to the patient's admission.
preadmission review	review for medical necessity of inpatient care prior to the patient's admission.
Preferrered Provider Health Care Act of 1985	eased restrictions on preferred provdier organizatoins (PPOs) and allowed subscribers to seek health care from providers outside of the PPO.
preferred provdier organization (PPO)	network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizatoions to provide health care to subscribers for a discounted fee.
primary care provider (PCP)	responsible for supervising and coordinating healthcare services for enrollees and preauthorizing referrals to spcialists and inpatient hospital admissions (except in emergencies).
prospective review	reviewing appropriateness and necessity of care provided to patients priorto administartion of care.
quality assessment and performance improvement (QAPI)	program implemented so that quality assurance activities are performed to improve the functioning of Medicare Advantage organiations.
quality assurance program	activities that assess the qualtiy of care provided in a healthcare setting.
Quality improvement System for Managed Care (QISMC)	established by Medicare to ensure the accountability of managed care plans in terms of objectibve, measurable standards.
report card	contains data regading a managed care plan's quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control.
retrospective review	reviewing appropriateness and necessity of care provided for patients after the administration.
risk contract	an arrangement among providrs to provide capitated (fixed, prepaid, basis) healthcare services to Medicare beneficiaries.
risk pool	created when a number of people are goryped for insurance puposes (e.g., employees of an orgnization); the cost of healthcare coverage is determined by employees' health status, age, sex, and occupaton.
second surgical opinion (SSO)	second physician is asked to evalujate the necssity of surgery and recommend the most economical, appropriate facility in which to perform the surgery ) e.g., outpatient clinic or doctor's office versus inpatient hospitilization).
self-referral	enrollee who sees a non-HMO panel specialist without a referral from the primary care physician.
staff model HMO	healthcare services are provided to subscribers by physicians employed by the HMO.
standards	requirements.
sub-capitation payment	each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider.
subscribers (policyholders)	person in whose name the insurance policy is issued.
survey	conducted by accreditation organizations (e.g., the Joint Commission) and/or regulatory agencies (e.g., CMS) to evaluate a facility's comliance with standards and/or regulations.
triple option plan	usually offered by either a single insurance plan or as a joint venture among two or more third-party payers, and provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans.
utilization management (utilization review)	method of controlling healthcare costs and qualtiy of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care.
utilization review organization (URO)	entity that establisheds a utilization management program and performs external utilization review services.
Camelia Clark Reimbursement	05/16/13

Created by: cameliaclark

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