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Ch. 3 Reimbursement

Managed Health Care

QuestionAnswer
Voluntary process that a healthcare facility or organization undergoes to demonstrate that it has met standards beyond those required by law. Accreditation
Covering members who are sicker than the general population. Adverse Selection
Legislation that allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be partially reimbursed. Amendment to the HMO Act of 1973
Also called triple option plan; provides different health benefit plans and extra coverage options through an insurer or third-party administrator. Cafeteria Plan
Provider accepts preestablished payments for providing healthcare services to enrollees over a period of time (usually one year). Capitation
Development of patient care plans to coordinate and provide care for complicated cases in a cost-effective manner. Case Management
Submits written confirmation, authorizing treatment, to the provider. Case Manager
Health care is provided in an HMO-owned center or satellite clinic or by physicians who belong to a specially formed medical group that serves the HMO> Closed-panel HMO
An HMO that meets federal eligibility requirements for a Medicare risk contract, but is not licensed as a federally qualified plan Competitive Medical Plan (CMP)
Review for medical necessity of tests and procedures ordered during an inpatient hospitalization. Concurrent Review
also called Consumer-driven Health Plan (CDHP); healthcare plan that encourages individuals to locate the best health care at the lowest possible price, with the goal of holding down costs Consumer-directed Health Plan (CDHP)
Managed care plan in which healthcare expenses are funded by insurance coverage; the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium; each provider is paid a fixed amount Customized Sub-capitation Plan (CSCP)
Contracted healthcare services delivered to subscribers by individual physicians in the community. Direct Contract Model HMO
Involves arranging appropriate healthcare services for the discharged patient Discharge Planning
Also called covered lives; employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans Enrollees
Managed care plan that provides benefits to subscribers if they receive services from network providers. Exclusive Provider Organization (EPO)
Responsible for reviewing health care provided by managed care organizations. External Quality Review Organization (EQRO)
Certified to provide healthcare services to Medicare and Medicaid enrollees. Federally Qualified HMO
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 (generic). Fee-for-service
see cafeteria plan and triple option plan; provides different health benefit plans and extra coverage options through an insurer or third-party administrator. Flexible Benefit Plan
also called health savings account; tax-exempt account offered by employers, which individuals use to pay healthcare bills; relatively inexpensive with a high deductible, and a tax-deductible savings account is opened to cover current and future medical Flexible Spending Account (FSA)
Prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement services. Gag Clause
Primary care provider for essential healthcare services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists. Gatekeeper
Contracted healthcare services delivered to subscribers by participating physicians who are members of an independent multispecialty group practice. Group Model HMO
Contract that allows physicians to maintain their own offices and share services Group Practice Without Walls (GPWW)
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 Effectiveness Data and Information Set (HEDIS)
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 Care Reimbursement Account (HCRA)
Responsible for providing healthcare services to subscribers in a given geographical area for a fixed fee. Health Maintenance Organization (HMO)
Authorized grants and loans to develop HMOs under private sponsorship; required most employers with more than 25 employees to offer HMO coverage if local plans were available Health Maintenance Organization Assistance Act of 1973
Tax-exempt accounts offered by employers with more than 50 employees; individuals use HRAs to pay healthcare bills; HRAs must be used for qualified healthcare expenses, require enrollment in a high-deductible policy, and can accumulate money Health Reimbursement Arrangement (HRA)
also called flexible spending account; tax-exempt account offered by employers, which individuals use to pay healthcare bills; relatively inexpensive with a high deductible, and a tax-deductible savings account is opened to cover current and future exp Health Savings Account (HSA)
also called health savings account; tax-exempt account offered by employers, which individuals use to pay healthcare bills; relatively inexpensive with a high deductible, and a tax-deductible savings account is opened to cover current and future medical Health Savings Security Account (HSSA)
Also called individual practice association (IPA); type of HMO where contracted health services are delivered to subscribers by physicians who remain in their independent office settings. Independent Practice Association (IPA) HMO
type of HMO where contracted health services are delivered to subscribers by physicians who remain in their independent office settings. Individual Practice Association (IPA) HMO
Organization of affiliated provider sites that offer joint healthcare srevices to subscribers. integrated Delivery System (IDS)
Manages the delivery of healthcare services offered by hospitals, physicians employed by the IPO, and other healthcare organizations. Integrated Provider Organization (IPO)
Laws. Legislation
Combines healthcare delivery with the financing of services provided. Managed Care
Responsible for the health of a group of enrollees; can be a health plan, hospital, physician group, or health system. Managed Care Organization (MCO)
Combines healthcare delivery with the financing services provided. Managed Health Care (managed care)
Usually owned by physicians or a hospital and provides practice management (administrative and support) services to individual physician practices. Management Service Organization (MSO)
Laws. Mandate
Nonprofit organization that contracts with and acquires the clinical and business assets of physician practices; the foundation is assigned a provider number and manages the practice's business. Medical Foundation
Tax-exempt trust or custodial account established for the purpose of paying medical expenses in conjunction with a high-deductible health plan; allows individuals to withdraw tax-free funds for healthcare expenses, which are not covered by a health plan. Medical Savings Account (MSA)
includes managed care plans and private fee-for-service plans, which provide care under contract to Medicare and may include such benefits as coordination of care, reductions in out-of-pocket expenses, and prescription drugs. Medicare+Choice
Federally qualified HMOs and competitive medical plans (CMPs) that meet specified Medicare requirements provide Medicare-covered services under a risk contract. Medicare Risk Program
A private, not-for-profit organization that assesses the quality of managed care plans in the US and releases the data to the public for its consideration when selecting a managed care plan. National Committee for Quality Assurance (NCQA)
Contracted healthcare services provided to subscribers by 2 or more physician multispecialty group practices. Network Model HMO
Physician or healthcare facility under contract to the managed care plan. Network Provider
CMS agency that facilitates innovation and competition among Medicare HMOs. Office of Managed Care
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. Open-panel HMO
Owned by the hospital and physician groups that obtain managed care plan contracts; physicians maintain their own practices and provide healthcare services to plan members. Physician-hospital Organization (PHO)
Requires managed care plans that contract with Medicare or Medicaid to disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval. Physician Incentive Plan
Include payments made directly or indirectly to healthcare providers to serve as encouragement to reduce or limit services (discharge an inpatient from the hospital more quickly) to save money for the managed care plan. Physician Incentives
Delivers healthcare services using both managed care network and traditional indemnity coverage so patients can seek care outside the managed care network. Point-of-Service Plan
Review for medical necessity of inpatient care prior to the patient's admission. Preadmission Certification (PAC)
Review for medical necessity of inpatient care prior to the patient's admission. Preadmission Review
Eased restrictions on preferred provider organizations (PPOs) and allowed subscribers to seek health care from providers outside of the PPO. Preferred Provder Health Care Act of 1985
Network of physicians and hospitals that have joined together to contract with insurance companies, employers or other organizations to provide health care to subscribers for a discounted fee. Preferred Provider Organization (PPO)
Responsible for supervising and coordinating healthcare services for enrollees and preauthorizing referrals to specialists and inpatient hospital admissions (except in emergencies). Primary Care Provider (PCP)
Reviewing appropriateness and necessity of care provided to patient prior to administration of care. Prospective Review
Program implemented so that quality assurance activities are performed to improve the functioning of Medicare Advantage organizations. Quality Assessment and Performance Improvement (QAPI)
Activities that assess the quality of care provided in a healthcare setting. Quality Assurance Program
Established by Medicare to ensure the accountability of managed care plans in terms of objective, measurable standards. Quality Improvement System for Managed Care (QISMC)
Contains data regarding a managed care plan's quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control. Report Card
Reviewing appropriateness and necessity of care provided to patients after the administration of care. Retrospective Review
An arrangement amoung providers to provide capitated (fixed, prepaid basis) healthcare services to Medicare beneficiaries. Risk Contract
Created when a number of people are grouped for insurance purposes (employees of an organization); the cost of healthcare coverage is determined by employees' health status, age, sex, and occupation. Risk Pool
Second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate faciliyt in which to perform the surgery (outpatient clinic or doctor's office versus hospitalization). Second Surgical Opinion (SSO)
Enrollee who sees a non-HMO panel specialist without a referral from the primary care physician. Self-Referral
Healthcare services are provided to subscribers by physicians employed by the HMO> Staff Model
Requirements. Standards
Each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider. Sub-Capitation Payment
Person in whose name the insurance policy is issued. Subscribers (policyholders)
Conducted by accreditation organizations and/or regulatory agencies (CMS) to evaluate a facility's compliance with standards and/or regulations. Survey
Usually offered by either a single insurance plan or as a joint venture among 2 or more third-party payers, and provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans; also called cafeteria plan or flexible Triple Option Plan
Method of controlling healthcare costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care. Utilization Management (utilization review)
Entity that establishes a utilization management program and performs external utilization review services. Utilization Review Organization (URO)
Created by: adale3171