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Chapter 3
| Term | Definition |
|---|---|
| QISMC= Quality Improvement System for Manager Care | Was established by Medicare to ensure accountability of managed care plans in terms of objective, measurable standards |
| PCP= Primary Care Physician | Provide care for enrollees on managed care plan |
| Joint Commission (JC) | Performs healthcare accreditation |
| Before scheduling an elective surgery | A second surgical opinion (SSO) may be required by the insurance company |
| Capitation | pre-established payments for healthcare services |
| Consumer-directed Health Plan (CDHP) | is NOT a managed care plan |
| Case Management | is development of patient care plans |
| A plan offered by a single insurance plan or joint venture by two or more insurance carriers and which provides subscribers or employees with a choice of HMO, PPO or traditional health plan can be called by the following names | Flexible benefits plan/ Cafeteria plan/ Triple option plan |
| Physician Incentives | encourage physicians/providers to reduce or limit services |
| Consumer-Directed Health Plan (CDHP) | provide incentives for controlling healthcare expenses and gives individuals an alternative to traditional health insurance and managed care coverage |
| Medical Foundation | is a nonprofit organization that contracts and acquires the clinical business assets of physician practices |
| Risk Pool | a number of people are grouped for insurance purpose and cost of healthcare coverage is determined by employees health status, age, sex and occupation |
| Point of Service (POS) Plan | patient may use HMO providers or self-refer to non-HMO providers |
| Customized Sub-Capitation Plan (CSCP) | a type of consumer-directed health plan (CDHP) where the individual selects one of each type of provider to create a customized network and pays the resulting the resulting customized insurance premium |
| MSO | provides practice management services to individual physician practices |
| The "Report Card" contains data regarding managed care plan's | quality utilization financial stability |
| Enrollees | are employees and dependents who join a managed care plan |
| PCP | is also referred to as a "Gatekeeper" |
| Gag Clause | prevents provider from discussing all treatment options with patients |
| Network Provider | Physician or healthcare provider under contract to a managed care plan |
| Managed healthcare was designed to | replace traditional free-for-service plans with more affordable quality healthcare to patients |
| PPO= Preferred Provider Organization | a network of physicians and hospitals that have joined together to contract with insurance companies, employers and other organizations to provide healthcare to subscribers for a discounted fee. |
| HMO is a health maintenance organization. It is an alternative to traditional group health insurance coverage provides | -Comprehensive healthcare services to -voluntarily enrolled members -on a prepaid basis |
| In a Managed care Plan | enrollees receive care from a primary care provider (PCP) who is a doctor that serves as a "gatekeeper" by providing essential health care services at the lowest possible cost |
| The Joint Commission (JC) | discontinued its Network Accreditation Program for Managed Care Organization in January 2006 |
| HMO= Health Maintenance Organization | provide preventative care services to promote wellness |
| Physician-Hospital Organization | is owned by hospital(s) and physician groups and obtain managed care contracts |
| The National Committee for Quality Assurance | is a non-profit organization that assesses the quality of managed care plans in the U.S. |
| Free-for-Service= | reimburses providers for individual healthcare services provided |
| Utilization Management/Review | is a method of controlling healthcare cost and quality of care by reviewing the appropriateness and necessity of care provided to patients |
| Examples of managed care plans are: | -Triple Option Plan (TOP) -Point of Service (POS) -Exclusive Provider Organization (EOP) |
| Accreditation= | voluntary process that a healthcare facility or organization undergoes to demonstrate it has met standards beyond those required by law |
| Managed Care Organization | is responsible for the health of a group of enrollees and can be health plan, hospital, physician group or health system |
| Case management= | the development of patient care plans for the coordination and provision of care complicated cases in a cost-effective manner |
| SSO= Second Surgical Opinion | the second physician is asked to evaluate the necessity of surgery and recommend the most economic, appropriate facility |
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