Ch 7: Terms (matching) Flashcards
The Changing Face of Managed Care
Types of health insurance that control the use of health services by their members so that they can control healthcare costs, the quality of care, or both
Managed Care
An interrelated system in which people and facilities communicate with one another and work together as a unit
Network
Individuals who are eligible for healthcare services and benefits under a specific managed care plan
Enrollees
Two common types of MCOs
- HMO (Health Maintenance Organization)
- PPO (Preferred Provider Organization)
Groups of healthcare providers who work under one umbrella to provide medical services at a discount to individuals who participate in the managed care plan
PPOs (Preferred Provider Organizations)
A specific provider who oversees HMO member’s total healthcare treatment
Primary Care Physician (PCP)
An arrangement made from a PCP to a specialist to take over a patient’s care
Referral
Type of insurance company that typically has no deductibles or plan limits
Health Maintenance Organizations (HMOs)
Managed care plans emphasize this type of healthcare
Preventative Healthcare
A multispecialty group practice in which all healthcare services are provided within the building(s) owned by the HMO
Staff model HMO
A model in which the HMO contracts with independent, multispecialty physician groups who provide all healthcare services to its members
Group model HMO
A fixed fee per member per specified time period (usually monthly)
Capitation
The staff model is considered what type of HMO?
Closed panel
This HMO is similar to n IPA except the HMO contracts directly with the individual physicians
Direct contract model
An IPA is what type of HMO?
Open-panel model
A type of HMO that has multiple provider arrangements, including staff, group, or IPA structures
Network model
A “hybrid” type of managed care (also referred to as open-ended HMO) that allows patients to use the HMO provider or go outside the plan and use any provider they choose
Point of service (POS) model
A system designed to determine the medical necessity and appropriateness of a medical service, procedure, or hospital admission
Utilization review
When the PCP request another physician to provide his or her expert opinion regarding the patient’s condition
Consultation
