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Health Ins and Claims Chapter 3

voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law accreditation
reimbursement where providers accept pre-established payments for providing health care services to enrollees over a period of time capitation
submits written confirmation, authorizing treatment, to the provider case manager
review for medical necessity of tests and procedures ordered during an inpatient hospitalization concurrent review
health care plan that encourages individuals to locate the best health care at the lowest possible price, with the goal of holding down costs by asking employees to be more responsible for health care decisions and cost-sharing. (CDHP)consumer-directed health plan
also called covered lives; employees and dependents who join a managed care plan enrollees
managed care plan that provides benefits to subscribers if they receive services from network providers (EPO) exclusive provider organization
reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services. fee-for-service
primary care provider for essential health care services at the lowest possible cost, avoiding non-essential care, and referring patients to specialists gatekeeper
tax-exempt account offered by employers with any number of employees, which individuals use to pay health care bills.It is usually in connection with a high deductible insurance plan. (HSA)health savings account
contracted health care services provided to subscribers by two or more physician multi-speciality group practices network model HMO
physician or health care facility under contract to the managed care plan network provider
include payments made directly or indirectly to health care providers to serve as encouragement to reduce or limit services to save money for the managed care plan. physician incentives
delivers health care services using both an HMO network and traditional indemnity coverage so patients can seek care outside the HMO network. (POS)point-of-service plan
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 (PPO)preferred provider organization
responsible for supervising and coordinating health care services for enrollees and preauthorizing referrals to specialists and inpatient hospital admissions (except in emergencies) primary care provider
reviewing appropriatementss and necessity of care provided to patients prior to administration of care. prospective review
reviewing appropriateness and necessity of care provided to patients after the administration of care. retrospective review
second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery. second surgical opinion
person in whose name the insurance policy is issued subscribers (policyholders)
method of controlling health care 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)
combines health care delivery with the financing of services provided managed health care (managed care)
owned by hospital(s) and physician groups that obtain managed care plan contracts; physicians maintain their own practices and provide health care services to plan members (PHO) physician-hospital organization
Created by: Kcompleta