Ch. 03 Managed Healthcare Flashcards
Bundled payment
A single payment for all services associated with an episode of care.
Capitation
Provider accepts pre-established payments to provide healthcare services to enrollees in a managed care plan over a period of time.
Case management
The goal of case management is the coordination and provision of cost effective healthcare.
CDHP
Consumer Directed Health Plan
Drug formulary
A list of generic and brand name prescription drugs covered by the managed care plan.
Enrollee
Employees and dependents who join a managed care plan; also known as beneficiaries in private insurance plans.
EPO
Exclusive Provider Organization,
a managed care plan that provides benefits to subscribers who are required to receive services from participating network providers.
Fee-for-service
Method of reimbursement where services are itemized and billed separately.
HDHP
High Deductible Health Plan
HMO
Health Maintenance Organization
an alternative to traditional group health insurance coverage, providing comprehensive health care services to voluntarily enrolled members on a prepaid basis.
HSA
Health Savings account
IDS
Integrated Delivery System, an organization of affiliated providers’ sites that offer joint healthcare services to subscribers.
Managed healthcare
A healthcare delivery system designed to keep the costs of care as low as possible without sacrificing access or quality.
NCQA
National Committee for Quality Assurance, a private, not-for-profit organization that assesses the quality of managed care plans in the U. S.
Network provider
Healthcare provider who is under contract to the managed care plan.
Out-of-network provider
Healthcare provider who is not under contract to the managed care plan.
POS
Point-of-service,
not an HMO, but it is a managed care plan that combines the characteristics of an HMO and a PPO.
PPO
Preferred Provider Organization,
a managed care 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.
Primary care provider
Responsible for supervising and coordinating healthcare services for enrollees in a managed care plan.
QA
Quality assurance, a program that assess the quality of care provided by managed care plans.
Referring physician
Directs a patient to another physician (usually a specialist) for diagnosis or treatment.
Reimbursement
Payment to healthcare providers for services rendered.
Risk pool
Individuals grouped together for insurance purposes, e.g., employees of an organization.
Specialist
A physician with advanced training in a specific area of medicine.
Triple Option Plan
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.
Utilization review (UR)
A method of controlling healthcare costs by focusing on the appropriate use of resources while ensuring the quality of care provided.
