Managed Health Care
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| Voluntary process that a healthcare facility or organization undergoes to demonstrate that it has met standards beyond those required by law. | show 🗑
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| Covering members who are sicker than the general population. | show 🗑
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| show | Amendment to the HMO Act of 1973
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| Also called triple option plan; provides different health benefit plans and extra coverage options through an insurer or third-party administrator. | show 🗑
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| Provider accepts preestablished payments for providing healthcare services to enrollees over a period of time (usually one year). | show 🗑
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| Development of patient care plans to coordinate and provide care for complicated cases in a cost-effective manner. | show 🗑
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| Submits written confirmation, authorizing treatment, to the provider. | show 🗑
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| show | Closed-panel HMO
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| An HMO that meets federal eligibility requirements for a Medicare risk contract, but is not licensed as a federally qualified plan | show 🗑
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| show | Concurrent Review
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| also called Consumer-driven Health Plan (CDHP); healthcare plan that encourages individuals to locate the best health care at the lowest possible price, with the goal of holding down costs | show 🗑
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| show | Customized Sub-capitation Plan (CSCP)
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| show | Direct Contract Model HMO
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| show | Discharge Planning
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| Also called covered lives; employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans | show 🗑
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| show | Exclusive Provider Organization (EPO)
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| Responsible for reviewing health care provided by managed care organizations. | show 🗑
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| Certified to provide healthcare services to Medicare and Medicaid enrollees. | show 🗑
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| 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 (generic). | show 🗑
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| see cafeteria plan and triple option plan; provides different health benefit plans and extra coverage options through an insurer or third-party administrator. | show 🗑
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| show | Flexible Spending Account (FSA)
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| show | Gag Clause
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| show | Gatekeeper
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| Contracted healthcare services delivered to subscribers by participating physicians who are members of an independent multispecialty group practice. | show 🗑
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| Contract that allows physicians to maintain their own offices and share services | show 🗑
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| Created standards to assess managed-care systems using data elements that are collected, evaluated, and published to compare the performance of managed healthcare plans. | show 🗑
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| show | Health Care Reimbursement Account (HCRA)
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| show | Health Maintenance Organization (HMO)
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| show | Health Maintenance Organization Assistance Act of 1973
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| show | Health Reimbursement Arrangement (HRA)
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| show | Health Savings Account (HSA)
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| show | Health Savings Security Account (HSSA)
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| Also called individual practice association (IPA); type of HMO where contracted health services are delivered to subscribers by physicians who remain in their independent office settings. | show 🗑
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| type of HMO where contracted health services are delivered to subscribers by physicians who remain in their independent office settings. | show 🗑
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| Organization of affiliated provider sites that offer joint healthcare srevices to subscribers. | show 🗑
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| Manages the delivery of healthcare services offered by hospitals, physicians employed by the IPO, and other healthcare organizations. | show 🗑
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| show | Legislation
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| Combines healthcare delivery with the financing of services provided. | show 🗑
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| Responsible for the health of a group of enrollees; can be a health plan, hospital, physician group, or health system. | show 🗑
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| show | Managed Health Care (managed care)
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| Usually owned by physicians or a hospital and provides practice management (administrative and support) services to individual physician practices. | show 🗑
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| show | Mandate
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| show | Medical Foundation
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| show | Medical Savings Account (MSA)
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| show | Medicare+Choice
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| show | Medicare Risk Program
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| A private, not-for-profit organization that assesses the quality of managed care plans in the US and releases the data to the public for its consideration when selecting a managed care plan. | show 🗑
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| show | Network Model HMO
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| Physician or healthcare facility under contract to the managed care plan. | show 🗑
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| show | Office of Managed Care
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| Health care provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO. | show 🗑
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| Owned by the hospital and physician groups that obtain managed care plan contracts; physicians maintain their own practices and provide healthcare services to plan members. | show 🗑
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| show | Physician Incentive Plan
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| Include payments made directly or indirectly to healthcare providers to serve as encouragement to reduce or limit services (discharge an inpatient from the hospital more quickly) to save money for the managed care plan. | show 🗑
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| Delivers healthcare services using both managed care network and traditional indemnity coverage so patients can seek care outside the managed care network. | show 🗑
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| show | Preadmission Certification (PAC)
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| show | Preadmission Review
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| show | Preferred Provder Health Care Act of 1985
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| show | Preferred Provider Organization (PPO)
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| show | Primary Care Provider (PCP)
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| Reviewing appropriateness and necessity of care provided to patient prior to administration of care. | show 🗑
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| Program implemented so that quality assurance activities are performed to improve the functioning of Medicare Advantage organizations. | show 🗑
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| show | Quality Assurance Program
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| show | Quality Improvement System for Managed Care (QISMC)
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| show | Report Card
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| Reviewing appropriateness and necessity of care provided to patients after the administration of care. | show 🗑
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| An arrangement amoung providers to provide capitated (fixed, prepaid basis) healthcare services to Medicare beneficiaries. | show 🗑
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| show | Risk Pool
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| show | Second Surgical Opinion (SSO)
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| show | Self-Referral
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| Healthcare services are provided to subscribers by physicians employed by the HMO> | show 🗑
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| Requirements. | show 🗑
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| Each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider. | show 🗑
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| Person in whose name the insurance policy is issued. | show 🗑
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| Conducted by accreditation organizations and/or regulatory agencies (CMS) to evaluate a facility's compliance with standards and/or regulations. | show 🗑
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| show | Triple Option Plan
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| 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. | show 🗑
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| Entity that establishes a utilization management program and performs external utilization review services. | show 🗑
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Created by:
adale3171
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