ljlindrose61 Word Scramble

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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)

Created by: ljlindrose61