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Health Ins. Chap. 3
Managed Health Care
| Question | Answer |
|---|---|
| accreditation | A voluntary process that a healthcare facility or organization undergoes to demonstrate that it has met standards beyond those required by law. |
| capitation | Providers accept pre-established payments for providing healthcare services to enrollees over a period of time (usually 1 year). |
| case manager | Submits written confirmation, authorizing treatment, to the provider. |
| concurrent review | A review for medical necessity of tests and procedures ordered during an inpatient hospitalization. |
| CDHP | consumer-directed health plan |
| enrollees | Employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans. |
| EPO | exclusive provider organization |
| fee-for-service | Reimburses providers for individual healthcare services rendered. |
| gatekeeper | Another term for the primary care provider who is responsible for supervising and coordinating healthcare services & approves referrals to specialists & inpatient hospital admissions. |
| HSA | health savings account |
| managed health care (managed care) | Combines healthcare delivery with the financing of services provided. |
| NCQA | National Committee for Quality Assurance |
| network model HMO | Contracted healthcare services are provided to subscribers by two or more physician multi-specialty group practices. |
| physician incentives | Payments made directly or indirectly to healthcare providers to encourage them to reduce or limit service so as to save money for the managed care plan. |
| PHO | physician hospital organization |
| POS | point-of-service |
| PPO | preferred provider organization |
| PCP | primary care provider |
| prospective review | A review of the appropriateness and necessity of care provided to patients prior to the administration of care. |
| retrospective review | A review of the appropriateness and necessity of care provided to patients after the administration of care. |
| SSO | second surgical opinion |
| subscribers (policyholders) | Employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans. |
| utilization management (utilization review) | A method of controlling healthcare costs and quality of care by reviewing the appropriateness and necessity of care provided to patients. |
| consumer-directed health plans (CDHPs) | Define employer contributions and ask employees to be more responsible for healthcare decisions and cost-sharing. |
| What is a managed care organization (MCO) responsible for? | It's responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system. |
| Who is responsible for supervising and coordinating healthcare services for enrollees? | primary care provider |
| What prevents providers from discussing all treatment options with patients? | gag clauses |
| What is the term called where providers accept pre-established payments for providing healthcare services to enrollees over a period of time? | capitation |
| This includes activities that assess the quality of care provided in a healthcare setting. | quality assurance program |
| What do managed care plans often require prior to scheduling elective surgery? | second surgical opinion (SSO) |
| This allows individuals to withdraw tax-free funds for healthcare expenses that are not covered by a qualifying high-deductible health plan. | health savings accounts |
| COBRA | Consolidated Omnibus Budget Reconciliation Act |
| Why was COBRA established? | Established an employee's right to continue healthcare coverage beyond scheduled benefit termination date. |
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