Ch 7: Review Test Flashcards
The Changing Face of Managed Care
An organized, interrelated system of people and facilities that communicate with one another and work together as a unit is commonly referred to as a ____?
Network
Individuals belonging to a managed healthcare plan are commonly referred to as what?
Enrollees
What are the two most common types of MCOs?
- HMO (Health Maintenance Organization)
- PPO (Preferred Provider Organization)
A specific provider who oversees an HMO member’s total healthcare treatment is called a ____?
Primary care physician (PCP)
The amount of money a patient has to pay out of pocket per visit is referred to as what?
Copayment
When an individual first enrolls in an HMO, he or she chooses a ____?
Primary care physician (PCP)
What do most healthcare plans emphasize?
Preventive healthcare
A multispecialty group practice in which all healthcare services are provided within the building(s) owned by the HMO is called a ____?
Staff model
A reimbursement system in which healthcare providers receive a fixed fee for every patient enrolled in the plan, regardless of how many or few services the patient uses, is called a(n) ____ system
Capitation
A managed care system composed of individual healthcare providers who offer healthcare services for HMO and non-HMO patients but maintain their own offices and identities is called what?
Open-panel IPA
A plan that allows patients to use the HMO provider or go outside the plan and pay a higher copayment and deductible is a(n) ____?
Open-end HMO
Most commercial healthcare organizations and MCOs request that they be made aware of and consent to certain procedures and services before their enrollees undergo them, a process called ____?
Precertification
The ____ process can help prevent situations in which the patient may be forced to pay significant out-of-pocket costs
Predetermination of benefis
A procedure required by third-party payers that requires permission before a provider can carry out specific procedures and treatments is a ____?
A “medical right to know”
A type of managed care organization that provides Medicare beneficiaries with alternatives to original Medicare is a(n) ____?
PSO
It is predicted that under the Affordable Care Act, managed care organizations will increase rapidly, particularly with the expansion of what?
Medicaid
Most MCOs are regulated from what three areas?
- States
- Federal government
- Voluntary accreditation
To provide quality, affordable care for all Americans and to promote wellness, prevention of disease, and early intervention are the goals of what?
The Affordable Care Act
An independent nonprofit organization that measures, assesses, and repots on the quality of care and service in MCOs is the ____?
NCQA (National Committee for Quality Assurance)
