Ch. 03 Managed Healthcare

Question 1

Bundled payment

Answer 1

A single payment for all services associated with an episode of care.

Question 2

Capitation

Answer 2

Provider accepts pre-established payments to provide healthcare services to enrollees in a managed care plan over a period of time.

Question 3

Case management

Answer 3

The goal of case management is the coordination and provision of cost effective healthcare.

Question 4

CDHP

Answer 4

Consumer Directed Health Plan

Question 5

Drug formulary

Answer 5

A list of generic and brand name prescription drugs covered by the managed care plan.

Question 6

Enrollee

Answer 6

Employees and dependents who join a managed care plan; also known as beneficiaries in private insurance plans.

Question 7

EPO

Answer 7

Exclusive Provider Organization,
a managed care plan that provides benefits to subscribers who are required to receive services from participating network providers.

Question 8

Fee-for-service

Answer 8

Method of reimbursement where services are itemized and billed separately.

Question 9

HDHP

Answer 9

High Deductible Health Plan

Question 10

HMO

Answer 10

Health Maintenance Organization
an alternative to traditional group health insurance coverage, providing comprehensive health care services to voluntarily enrolled members on a prepaid basis.

Question 11

HSA

Answer 11

Health Savings account

Question 12

IDS

Answer 12

Integrated Delivery System, an organization of affiliated providers’ sites that offer joint healthcare services to subscribers.

Question 13

Managed healthcare

Answer 13

A healthcare delivery system designed to keep the costs of care as low as possible without sacrificing access or quality.

Question 14

NCQA

Answer 14

National Committee for Quality Assurance, a private, not-for-profit organization that assesses the quality of managed care plans in the U. S.

Question 15

Network provider

Answer 15

Healthcare provider who is under contract to the managed care plan.

Question 16

Out-of-network provider

Answer 16

Healthcare provider who is not under contract to the managed care plan.

Question 17

POS

Answer 17

Point-of-service,
not an HMO, but it is a managed care plan that combines the characteristics of an HMO and a PPO.

Question 18

PPO

Answer 18

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.

Question 19

Primary care provider

Answer 19

Responsible for supervising and coordinating healthcare services for enrollees in a managed care plan.

Question 20

QA

Answer 20

Quality assurance, a program that assess the quality of care provided by managed care plans.

Question 21

Referring physician

Answer 21

Directs a patient to another physician (usually a specialist) for diagnosis or treatment.

Question 22

Reimbursement

Answer 22

Payment to healthcare providers for services rendered.

Question 23

Risk pool

Answer 23

Individuals grouped together for insurance purposes, e.g., employees of an organization.

Question 24

Specialist

Answer 24

A physician with advanced training in a specific area of medicine.

Question 25

Triple Option Plan

Answer 25

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.

Question 26

Utilization review (UR)

Answer 26

A method of controlling healthcare costs by focusing on the appropriate use of resources while ensuring the quality of care provided.