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ljlindrose61
Chapter 3 - Health Ins & Claims
| Question | Answer |
|---|---|
| Combines healthcare delivery with the financing of services provided. | managed health care (managed care) |
| Managed care is currently being challenged by the growth of what? | consumer-directed health plans (CDHPs) |
| Reimbursement methodology that increases payment if the healthcare 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 |
| Plan which reimburse providers for indiidual healthcare services rendered. | fee-for-serviced plan |
| Responsible for supervising and coordinating healthcare services for enrollees and approves referrals to specialists and inpatient hospital admissions (except in emergencies). | primary care provider (PCP) |
| Method of controlling healthcare 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) |
| Reviewing appropriateness 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 |
| Review for medical necessity of inpatient care prior to the patient's admission. | preadmission certification (PAC) |
| Review that grants prior approval for reimbursement of a healthcare service (e.g., elective surgery). | preauthorization |
| Review for medical necessity of tests and procedures ordered during an inpatient hospitalization. | concurrent review |
| Involves arranging appropriate healthcare services for the discharged patient (e.g., home health care). | discharge planning |
| Involves the development of patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner. | case management |
| Responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system. | managed care organization (MCO) |
| An entity that establishes a utilization management program and performs external utilization review services. | utilization review organization (URO) |
| A second physician is asked to evaluate the necessity of elective surgery and recommend the most economical, appropriate facility in which to perform surgery. | second surgical opinion (SSO) |
| Prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services. | gag clause |
| Includes payments made directly or indirectly to healthcare providers to encourage them to reduce or limit services so as to save money for the managed care plan. | physician incentives |
| Requires managed care plans that contract with Medicare and Medicaid to disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval. | physican incentive plan |
| Managed care organizations (MCOs) were created to manage benefits and to develop participating provider networks. Managed care can now be categorized according to six models. | exclusive provider organization (EPO); integrated delivery system (IDS); health maintenance organization (HMO); point-of-service plan (POS); preferred provider organization (PPO); triple option plan |
| Managed care plan that provides benefits to subscribers who are required to receive services from netowrk providers. | exclusive provider organization (EPO) |
| Organization of affiliated providers' sites that offer joint healthcare services to subscribers. | integrated delivery system (IDS) |
| An alternative to traditional grup health insurance coverage and provides comprehensive healthcare services to volulntarily enrolled members on a prepaid basis. | health maintenance organization (HMO) |
| Patients have freedom to use the managed panel of providers or to self-refer to non-managed care providers. | point-of-service plans (POS) |
| 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. | preferred provider organization (PPO) |
| Usually offered either by a single insurance plan or as a joint venture among two or more insurance payers, provides subscribers or employees with a choice of HMO< PPO, or traditional health insurance plans. | triple option plan |
| Healthcare plan that encourages individuals to locate the best health care at the lowest possible price, with the goal of holding down costs; also called consumer-directed health plan. | consumer-directed health plan (CDHP) |
| Voluntary process that a healthcare facility or organization undergoes to demonstrate that it has met standards beyond those required by law. | accreditation |
| A private, not-for-profit organization that assesses the quality of managed care plans in the United States and releases data to the public for consideration when selecting a managed care plan. | National Committee for Quality Assurance (NCQA) |
| Managed care organizations (MCOs) impact a practice's administrative procedures by requiring ______________. | up-to-date lists of special administrative procedures required by each managed care plan contract. |
| Participants enroll in a relatively inexpensive high-deductible insurance plan, and a tax-deductibnle savings account is opened to cover current and future medical expenses. | health savings account (HSA) |
| Employees and dependents who join a managed care plan. | enrollees |
| Person in whose name the insurance policy is issued. | subscriber (policyholder) |
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ljlindrose61