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chapter 3
MANAGED HEALTH CARE
| Term | Definition |
|---|---|
| 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 |
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