Chapter 3
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| QISMC= Quality Improvement System for Manager Care | Was established by Medicare to ensure accountability of managed care plans in terms of objective, measurable standards
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| PCP= Primary Care Physician | Provide care for enrollees on managed care plan
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| Joint Commission (JC) | Performs healthcare accreditation
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| Before scheduling an elective surgery | A second surgical opinion (SSO) may be required by the insurance company
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| Capitation | pre-established payments for healthcare services
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| Consumer-directed Health Plan (CDHP) | is NOT a managed care plan
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| Case Management | is development of patient care plans
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| 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
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| Physician Incentives | encourage physicians/providers to reduce or limit services
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| Consumer-Directed Health Plan (CDHP) | provide incentives for controlling healthcare expenses and gives individuals an alternative to traditional health insurance and managed care coverage
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| Medical Foundation | is a nonprofit organization that contracts and acquires the clinical business assets of physician practices
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| 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
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| Point of Service (POS) Plan | patient may use HMO providers or self-refer to non-HMO providers
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| 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
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| MSO | provides practice management services to individual physician practices
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| The "Report Card" contains data regarding managed care plan's | quality
utilization
financial stability
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| Enrollees | are employees and dependents who join a managed care plan
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| PCP | is also referred to as a "Gatekeeper"
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| Gag Clause | prevents provider from discussing all treatment options with patients
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| Network Provider | Physician or healthcare provider under contract to a managed care plan
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| Managed healthcare was designed to | replace traditional free-for-service plans with more affordable quality healthcare to patients
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| 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.
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| 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
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| 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
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| The Joint Commission (JC) | discontinued its Network Accreditation Program for Managed Care Organization in January 2006
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| HMO= Health Maintenance Organization | provide preventative care services to promote wellness
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| Physician-Hospital Organization | is owned by hospital(s) and physician groups and obtain managed care contracts
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| The National Committee for Quality Assurance | is a non-profit organization that assesses the quality of managed care plans in the U.S.
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| Free-for-Service= | reimburses providers for individual healthcare services provided
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| 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
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| Examples of managed care plans are: | -Triple Option Plan (TOP)
-Point of Service (POS)
-Exclusive Provider Organization (EOP)
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| Accreditation= | voluntary process that a healthcare facility or organization undergoes to demonstrate it has met standards beyond those required by law
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| Managed Care Organization | is responsible for the health of a group of enrollees and can be health plan, hospital, physician group or health system
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| Case management= | the development of patient care plans for the coordination and provision of care complicated cases in a cost-effective manner
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| 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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