chapter 14 Flashcards
A traditional service type of provider (i.e., Blue Cross) pays covered amounts directly to the hospital or physician on a usual, customary and reasonable (UCR) charge basis. Any remaining balance is billed to and paid by the insured.
service basis
process of controlling how policyowners utilize their policies.
managed care
an insured typically will pay more out-of-pocket expenses for those surgeries for which that insured only obtained one surgical opinion. The mandatory second surgical option provision can help contain the cost of a group medical plan.
mandatory second opinions
includes annual physical exams and other procedures that help detect illnesses and medical problems early.
preventative care
The advances in medicine now permit many surgical procedures to be performed on an outpatient basis
ambulatory surgery
et the insurer take an active role in the management of what could potentially become a very costly claim.
case management
reviews are performed on a prospective basis, a concurrent basis, a retrospective basis, or a combination of all three.
case management
To control hospital claims and prevent unnecessary medical costs, many policies today require policy owners to obtain approval from the insurer before entering a hospital for elective surgeries
precertification
It involves monitoring the care’s appropriateness, the setting, and the length of time spent in the hospital.
concurrent review
involves the review of medical records after medical treatment. An insurance company can use the results to approve or deny coverage someone already received.
retrospective review
This use of PCP referrals is known as
the gatekeeper system
is a group insurance marketing method that benefits employers with a small number of employees. It combines multiple employers (10 or more) into a single pool for the purpose of providing group insurance.
Multiple Employer Trusts (MET)
tax-exempt entities that consist of two or more employers who have joined to provide affordable health benefits for their employees on a self-funded (or self-insured) basis.
A Multiple Employer Welfare Arrangement (MEWA)
Its purpose is to provide hospital and medical expense insurance protection to those aged 65 and older.
medicare
a system of “managed competition” through which employee health benefits are provided to civilian government employees and annuitants of the United States government
The Federal Employees Health Benefits (FEHB)
