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Chapter 3 Insurance
Question | Answer |
---|---|
The intent of managed health care was to | replace fee-for-service plans with affordable, quality care to health care consumers. |
The Medical Center received a $100,000 capitation payment in January to cover the health care costs of 150 managed care enrollees. By the following January, $80,000 had been expended to cover services provided. The remaining $20,000 is | retained by the Medical Center as profit. |
A nonprofit organization that contracts with and acquires the clinical and business assets of physician practices is called a | medical foundation. |
Which is responsible for supervising and coordinating health care services for enrollees and approves referrals to specialists? | primary care provider (PCP) |
The term that describes requirements created by accreditation organizations is | standards |
Which administrative procedure should a medical practice follow when it contracts with a managed care organization (MCO)? | Maintain separate bookkeeping systems for each capitated plan. |
Which is a voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law? | accreditation |
Which define employer contributions and ask employees to be more responsible for health care decisions and cost-sharing? | consumer-directed health plans |
Contracted network of health care providers that provide care to subscribers for a discounted fee. | PPO |
Organization of affiliated providers' sites that offer joint health care services to subscribers. | IDS |
Provides benefits to subscribers who are required to receive services from network providers. | EPO |
Patients can use the managed care panel of providers (paying discounted health care costs) or self-refer to out-of-network providers (and pay higher health care costs). | POS |
Managed Care Organization (MCO) | is responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system |
Fee-For-Service | reimburse providers for individual health care services rendered, managed care is financed according to a method called capitation, where providers accept preestablished payments for providing health care services to enrollees over a period of time |
PCP serves as a ____ | gatekeeper |
Gatekeeper | providing essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists. |
Utilization Management | a method of controlling health care costs and quality of care |