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chapter 3

MANAGED HEALTH CARE

TermDefinition
ACCREDITATION VOLUNTARY PROCESS THAT A HEALTHCAREFACILITY OR ORGANIZATION UNDERGOES TO DEMONSTRATE THAT IT HAS MET STANDARDS BEYOND THOSE REQUIRED BY LAW
ADVERSE SELECTION COVERING MEMBERSWHO ARE SICKER THAN THE GENERAL POPULATION
AMENDMENT TO THE HMO ACT OF 1973 LEGISLATION THAT ALOWED FEDERALLY QUALIFIED HMOS TO PERMIT MEMBERS TO OCCASIONALLY USE NON HMO PHYSICIANS AND BE PARTIALLY REIMBURSED
CAFETERIA PLAN ALSO CALLED TRIPLE OPTION PLAN, PROVIDES DIFFERENT HEALH ENEFIT PLANS ANDEXTRA COVERAGE OPTIONS THROUGHAN INSURER OR THIRD PARTY ADMINISTRATOR
CAPITATION PROVIDER ACCEPTS PREESTABLISHED PAMENTS FOR PROVIDING HEALTHCARE SERVICES TO ENROLLEES OVER A PEROID OF TIME
CASE MANAGEMENT DEVELOPMENT OF PATIENT CARE PLANS TO COORINAE AND PROVIDE CARE FOR COMPLICATED CASES IN A COST EFFECTIVE MANNER
CASE MANAGER SUBMITS WRITTEN CONFIRMATION, AUTHORIZING TREATMENT, TO THE PROVIDER
CLOSED-PANEL HMO HEALTH CARE IS PROVIDED IN AN HMO OWNED CENTER SATELLITE CLINIC OR BY PHYSICIANS WHO BELONG TO A SPECIALLY FORMED MEDICAL GROUP THAT SERVES THE HMO
COMPETITVE MEDICAL PLAN AN HMO THAT MEETS FEDERAL ELIGIBILITY REQUIREMENTS FOR A MEDICARE RISK CONTRACT, BUT IS NOT LICENSED AS A FEDERALLY QUALIFIED PLAN
CONCURRENT REVIEW REVIEW FOR MEDICAL NECESSITY OF TESTSAND PROCEDURES ORDERED DURING AN INPATIENT HOSPITALIZATION
CONSUMER-DIRECTED HEALTH PLAN HEALTHCARE PLAN THAT ENCOURAGES INDIVIDUALS TO LOCATE THE BEST HEALTH CARE AT THE LOWEST POSSIBEL PRICE, WITH THE GOAL OF HODING DOWN COSTS; AND SHOP FOR THE BEST CREDIT DEAL
CUSTOMIZD SUB CAPITATION PLAN MANAGED CARE PLAN IN WHICH HEALTHCARE EXPENSES ARE FUNDED BY SURANCE COVERAGE, INDIVIDUAL SELECTS ONE OF EACH TYPE OF PROVIDER TO CREATE A CUSTOMIZED INSURANCE PREMIUM
DIRECT CONTRACT MODEL HMO CONTRACTED HEALTHCARE SERVICES DELIVERED TO SUBSCRIBERS BY INDIVIDUAL PHYSICIANS IN THE COMMUNITY
DISCHARGE PLANNING INVOLVES ARRANGING APPROPRIATE HEALTHCARE SERVICES FOR THE DISCHARGED PATIENT
ENROLLEES ALSO CALLED COVERED LIVES; EMPLOYEES AND DEPENDENTS WHO HOIN A MANAGED CARE PLAN;KNOWN AS BENEFICIARIES IN PRIVATE INSURANCE PLANS
EXCLUSIVE PROVIDER ORGANIZATION MANAGED CARE PLAN THAT PROVIDES BENEFITS TO SUBSCRIBERS IF THEY RECEIVE SERVICES FROM NETWORK PROVIDERS
FEDERALY QUALIFIED HMO CERTIFIED TO PROVIDE HEALTHCARE SERVICES TO MEDICARE AND MEDICAID ENROLLEES
FEE FOR SERVICE REIMBURSEMENT METHODOLOGY THAT INCREASES PAYMENT IF THE HEALTHCARE SERVICE FEES INCREASE
FLEXIBLE SPENDING ACCOUNT TAX EXEMPT ACCOUT OFFERED BY EMPLOYERS WITH ANY NUMBER OF EMPLOYEES, WHICH INDIVIDUALS USE TO PAY HEALTHCARE BILLS
GAG CLAUSE PREVENTSPROVIDERSFROM DISCUSSING ALL TREATMENT OPTIONS WITH PATIENTS, WHETHER R NOT THE PLAN WOULD PROVIDE REIMBURSEMET FOR SERVICES
GATEKEEPER PRIARY CARE PROVIDER FOR ESSENTIAL HEALTHCARE SERVICES AT THE LOWEST POSSIL COST, AVOIDING NONESSENTIAL CARE, AND REFERRING PATIENTS TO SPECIALISTS
GROUP MODEL HMO CONTRACTED HEALTHCARE SERVICES DELIVERED TO SUBSCRIBERS BY PARTICIPATING PHYSICIANS WHO ARE MEMBERS OF AN INDEPENDENT MULTISPECIALTY GROUP PRACTICE
GOUP PRACTICE WITHOUT WALLS CONTRACT THAT ALLOWS PHYSICIANS TO MAINTAIN THEIR OWN OFFICES AND SHARE SERVICES
HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET CREATED STANDARDS TO ASSESS MANAGED CARE SYSTEMS USING DATA ELEMENTS THAT ARE COLLECTED, AND PUBLISHED TO COMPARE THE PERFORMANCE OF MANAGED HEALTHCARE PLANS
HEALTHCARE REIMBURSEMENT ACCOUNT TAX EXMPT ACCOUNT USED TO PAY FOR HEALTHCARE EXPENSES
HEALTH MAINTENANCE ORGANIZATION RESPONSIBLE FOR PROVIDING HEALTHCARE SERVICESTO SUBSCRIBERS IN A GIVEN GEOGRAPHCAL AREA FOR A FIXED FEE
HEALTH MAINTENANCE ORGANIZATION ASSISTANCE ACT OF 1973 AUTHORIZED GRANTS AND LOANS TO DEVELOP HMOS UNDER PRIVATE SPONSORSHIP
HEALTH REMBURSEMENT ARRANGEMENT TAX EXEMPT ACCOUNTS OFFERED BY EMPLOYERS WIH MORE THAN 50 EMPLOYEES TO PAY HEALTHCARE BILLS
INDIVIDUAL PRACTICE ASSOCIAION HMO TYPE OF HMO WHERE CONTRACTED HEALTH SERVICES ARE DELIVERED TO SUBSCRIBERS BY PHYSICIANS WO REMAIN IN THEIR INDEPENDENT OFFICE SETTINGS
INTEGRATED DELIVERY SYSTEM ORGANIZATION OF AFFILIATED PROVIDER SITES THAT OFFER JOINT HEALTHCARE SERVICES TO SUBSCRIBERS
INTEGRATED PROVIDER ORGANIZATION MANAGES THE DELIVERY OF HEALTHCARE SERVICES OFFERED BY HOSPITALS, PHYSICIANS EMPLOYED BY THE IPO, AND HEALTHCARE ORGANIZATIONS
LEGISLATION LAWS
MANAGED CARE ORGANIZATION RESPONSIBLE FOR THE HEALTH OF A GROUP OF ENROLLEES; CAN BE A HEALTH PLAN HOSPITAL, PHYSICIAN GROUP, OR HEALTH SYSTEM
MANAGED HEALTH CARE COMBINES HEALTHCARE DELIVERY WITH THE FINANCING OF SERVICES PROVIDED
MANAGEMENT SERVICE ORGANIZATION USUALLY OWNED BY PHYSICIANS OR A HOSPITAL AND PROVIDES PRACTICE MANAGEMENT SERVICES TOINDIVIDUAL PHYSICIAN PRACTICES
MANDATES LAWS
MEDICAL FOUNDATION NONPROFIT ORGANIZATION THAT CONTRACTS WITH AND AXQUIRES THE CLINICAL AND BUSINESS ASSETS OF PHYSICIAN PRACTICES
MEDICAL SAVINGS ACCOUNT TAX EXEMPT TRUST OR CUSTODIAL ACCOUNT ESTABLISHED FOR THE PURPOSE OF PAYING MEDICAL EXPENSES IN CONJUNTION WITH A HIGH DEDUCTIBLE HEALTH PLAN
MEDICARE+CHOICE INCLUDES MANAGEDCARE PLANS AND PRIVATE FEE FOR SERVICE PLANS WHICH PROVIDE CARE NDER CONTRACT TO MEDICARE AND MAY INCLUDE SUCH BENEFITS AS COORDINATION OF CARE
MEDICARE RISK PROGRAM FEDERALLY QUALIFIED HMOS ANDCOMPETITIVE MEDICAL PLANS THAT MEET SPECIFIED MEDICARE REQUIREMENS PROVIDE MEDICARE COVERED SERVICES UNDER A RISK CONTRACT
NATIONAL COMMITTEE FOR QUALITY ASSURANCE 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
NEWORK MODEL HMO CONTRACTED HEALTHCARE SERVICES PROVIDED O SUBSCRIBERS BY TWO ORMORE PHYSICIAN MULTISPECIALTY GROUP PRACTICES
NETWORK PROVIDER PHYSICIAN OR HEALTHCAREFACILITY UNDER CONTRACTTO THE MANAGED CARE PLAN
OFFICE OF MANAGED CARE CMS AGENCY THAT FACILITATES INNOVATION AND COMPETITION AMONGMEDICARE HMOS
OPEN PANEL HMO HEALTH CARE PROVIDED BY INDIVIDUALSWHO ARE NOT EMPLOYEES OF THE HMO OR WHODONOT BELONG TO A SPECIALLY FORMED MEDICAL GROUP THAT SERVES THE HMO
PHYSICIAN INCENTIVE PLAN REQUIRES MANAGED CARE PLANS THAT CONTACT WITH MEDICARE OR MEDCAID TO DISCLOSE INFORMATION ABOUT PHYSICIAN INCENTIVE PLANSTO CMS OR STATE MEDICAID AGENCIES BEFORE A NEW OR RENEWED CONTRACT RECEIVES FINAL APPROVAL
PHYSICIAN INCENTIVES INCLUDE PAYMENTS MADE DIRECTLY OR INDIRECTLY TO HEALTHCARE PROVIDERS TO SERVE AS ENCOURAGEMENT TO REDUCE OR LIMIT SERVICES TO SAVE MONEY FOR THE MANAGED CARE PLAN
PHYSICIAN HOSPITAL ORGANIZATION OWNED BY HOSPITAL AND PHYSICIAN GROUPS THAT OBTAIN MANAGED CARE PLAN CONTRACT; PHYSICIANS OWN PRACTICES AND PROVIDE HEALTHCARE SERVICES TO PLAN MEMBERS
POINT OF SERVICE PLAN DELIVERS HEALTHCARE SERVICES USINGBOTH MANAGEDCARE NETWORK AND TRADITIONAL INDEMNITY COVERAGE SO PATIENTS CAN SEEK CARE OUTSIDE THE MANAGED CARE NETWORK
PREADMISSION CERTIFICATION REVIEW FOR MEDICAL NECESSITY OF INPATIENT CARE RIOR TO THE PATIENT'S ADMISSION
PREADMISSION REVIEW REVIEW FOR MEDICAL NECESSITY OF INPATIENT CARE PRIOR TO THEPATIENT'S ADMISSION
PREFERRED PROVIDER HEALTH CARE ACT OF 1985 EASED RESTRICTIONS ON PREFERRED PROVIDER ORGANIZATIONS ANDALLOWEDSUBSCRIBERS TO SEEK HEALTH CARE FROM PROVIDERS OUTSDE OF THE PPO
PREFERRED PROVIDERORGANIZATION NETWORK OF PHYSICIANS AND HOSPITALS THATHAVE JOINED TOGETHER TO CONTRACT WITH INSURANCE COMPANIES, EMPLOYERS, OR OTHER ORGANIZATIONS TO PROVIDE HEALTHCARE TO SUBSCRIBERS FOR A DISCOUTED FEE
PRIMARY CARE PROVIDER RESPONSIBLE FOR SUPERVISING AND COORDINATING HEALTHCARE SERVICES FORENROLLEES AND REAUTORIZING REFERRALS TO SPECIALISTS AD INPATIENT HOSPITAL ADMISSIONS
PROSPECTIVE REVIEW REVIEWING APPROPRIATENESS AND NECESSITY OF CARE PROVIDED TO PATIENTS PRIOR TO ADMIISTRATION OF CARE
QUALITY ASSESSMENT AND PERORMANCE IMPROVEMENT PROGRAM IMPLEMENTED SO THAT QUALITY ASSURANCE ACTIVITIES ARE PERFORMED TO IMPROVE THE FUNCTIONING OF MEDICARE ADVANTAGE ORGANIZATIONS
QUALITY ASSURANCE PROGRAM ACTIVITIES THAT ASSESS THEQUALITY OF CARE PROVIDED IN A HEALTHCARE SETTING
QUALITY IMPROVEMENT SYSTEM FOR MANAGED CARE ESTABLISHED BY MEDICARE TO ENSURE THE ACCOUNTABILITY OF MANAGED CARE PLANS IN TERMS OFOBJECTIVE, MEASURABL STANDARDS
REPORT CARD CONTAINS DATA REGARDING A ANAGED CARE PLAN'S QUALITY, UTILIZATION, CUSTOMER SATISFACION, ADMINISTRATIVE EFFECTIVENESS, FINANCIAL STABILITY, AND COST CONTROL
RETROSPECTIVE REVIEW REVIEWING APPROPRIATENESS AD NECESSITY OF CARE PROVIDED TO PATIENTS AFTER THE ADMINISTARATION OF CARE
RISK CONTRACT AN ARRANGEMENT AMONG PROVIDERS TO PROVIDE CAPITATED HEALTHCARE SERVICES TO MEDICARE BENEFICIARIES
RISK POOL CREATED WHEN A NUMBER OF PEOPLE ARE GROUPED FOR INSURANCE PURPOSES THE COST OF HEALTHCARE COVERAGE IS DETERMINED BY EMPLOYEES HEALTH STATUS, AGE, SEX AND OCCUPTATION
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 POVIDE ONLY THE CARE THAT AN INDIVIDUAL NEEDS FROM THAT PROVIDER
SUBSCRIBERS PERSON IN WHOSE NAME THE INSURANCE POLICY IS ISSUED
SURVEY CONDUCTED BY ACCREDITATION ORGANIZATIONS AND OR REGULATORY AGENCIES TO EVALUATE A FACILITY'S COMPLIANCE WITH STANDARDS AND REGULATIONS
TRIPLE OPTION PLAN USUALLY OFFERED BY EITHER A SINGLE INSURANCE PLAN OR AS A OINT VENTURE AMONG TWO 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 FLEXIBLEENEFI
UTILIZATION MANGEMENT METHOD OF CONTROLLING HEALTHARE COSTS AND QUALITY OF CARE BY REVIEWING THE APPROPRIATENESS AND NECESSITY OF CARE PROVIDED TO PATIENTS PRIOR TO THE ADMINISTRATION OF CARE
UTILIZATION REVIEW ORGANIZATION ENTITY THAT ESTABLISHES A UTILIZATION MANAGEMENT PROGRAM AND PERFORMS EXTERNAL UTILIZATION REVIEW SERVICES
Created by: mmoore8209