Managed Health Care
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| accreditation | A voluntary process that a healthcare facility or organization undergoes to demonstrate that it has met standards beyond those required by law.
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| capitation | Providers accept pre-established payments for providing healthcare services to enrollees over a period of time (usually 1 year).
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| case manager | Submits written confirmation, authorizing treatment, to the provider.
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| concurrent review | A review for medical necessity of tests and procedures ordered during an inpatient hospitalization.
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| CDHP | consumer-directed health plan
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| enrollees | Employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans.
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| EPO | exclusive provider organization
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| fee-for-service | Reimburses providers for individual healthcare services rendered.
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| gatekeeper | Another term for the primary care provider who is responsible for supervising and coordinating healthcare services & approves referrals to specialists & inpatient hospital admissions.
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| HSA | health savings account
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| managed health care (managed care) | Combines healthcare delivery with the financing of services provided.
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| NCQA | National Committee for Quality Assurance
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| network model HMO | Contracted healthcare services are provided to subscribers by two or more physician multi-specialty group practices.
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| 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.
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| PHO | physician hospital organization
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| POS | point-of-service
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| PPO | preferred provider organization
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| PCP | primary care provider
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| prospective review | A review of the appropriateness and necessity of care provided to patients prior to the administration of care.
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| retrospective review | A review of the appropriateness and necessity of care provided to patients after the administration of care.
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| SSO | second surgical opinion
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| subscribers (policyholders) | Employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans.
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| 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.
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| consumer-directed health plans (CDHPs) | Define employer contributions and ask employees to be more responsible for healthcare decisions and cost-sharing.
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| 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.
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| Who is responsible for supervising and coordinating healthcare services for enrollees? | primary care provider
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| What prevents providers from discussing all treatment options with patients? | gag clauses
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| What is the term called where providers accept pre-established payments for providing healthcare services to enrollees over a period of time? | capitation
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| This includes activities that assess the quality of care provided in a healthcare setting. | quality assurance program
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| What do managed care plans often require prior to scheduling elective surgery? | second surgical opinion (SSO)
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| 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
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| COBRA | Consolidated Omnibus Budget Reconciliation Act
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| Why was COBRA established? | Established an employee's right to continue healthcare coverage beyond scheduled benefit termination date.
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