Glossary of Managed Care Definitions Flashcards
1
Q
Accredidation
A
a systematic review of a managed care plan by one of three private, nonprofit agencies (the National Committee for Quality Assurance, the Joint Commission on the Accreditation of Health Care Organizations, and the American Accreditation HealthCare Commission/Utilization Review Accreditation Commission).
2
Q
Actual Charge
A
the price levied by a health care provider (for example, a hospital or physician) on a consumer or a managed care plan, for a specific medical product or service.
3
Q
Acturial
A
methods and calculations used to estimate the financial risk for a managed care plan of enrolling a specific consumer or group of consumers
4
Q
acute care
A
short-term treatment for an illness that is limited in its duration
5
Q
acute illness
A
an ailment (illness or injury) that is limited in its duration and resolves before becoming chronic and requiring on-going management.
6
Q
administrative costs
A
expenses related to running an organization, such as overhead (rent, utilities, and supplies), advertising and marketing.
7
Q
Adverse Selection
A
a situation in which a managed care plan’s population of consumers is older or sicker than expected and, consequently, more likely to incur higher expenses for the plan.
8
Q
Allowable Charge
A
amount that a managed care plan determines is the appropriate amount to pay health care provider for a specific product or service
9
Q
Alternative Health Care
A
products and services such as acupuncture, homeopathy, nutrition therapy, and massage, that can complement the services provided by hospitals and physicians.
10
Q
American Accreditation HealthCare Commission/ Utilization Review Assessment
Commission (URAC)
A
a private, nonprofit agency located in Washington, D.C., that reviews managed care plans against its own performance standards.
11
Q
Ancillary Services
A
imaging (such as x-rays and CAT scans) and laboratory testing (such as blood or urine testing) that are provided to a consumer in conjunction with hospital or physician care to assist with diagnosis and
treatment.
12
Q
any willing provider
A
laws that require managed care plans, such as health maintenance organizations, to contract with all physicians or hospitals in the area served by the plan who wish to serve the plan’s members.
13
Q
Appeal
A
review of an adverse coverage decision by a managed care plan
14
Q
Assignment
A
process by which a health care provider, such as a physician, agrees to accept payment for a product or service directly from the managed care plan.
15
Q
At-risk
A
a situation that occurs when a health care provider receives a fixed, predetermined sum of money to care for a consumer (or group of consumers) and stands to lose money if total expenses for care exceed the amount paid.
16
Q
Authorization
A
approval by a managed care plan for a consumer to receive a health care product or service, such as a specific medical treatment, surgical procedure, or diagnostic test.
17
Q
Balanced Billing
A
a system in which a health care provider can collect from a consumer the difference between the provider’s actual charge and the insurer’s allowable charge.
18
Q
Behavioral Health care
A
products and services intended to diagnose and treat mental and emotional illnesses, such as depression or substance abuse.
19
Q
Benefit limit
A
caps on how much the managed care plan will pay for specific health care products or services, or the quantity of services a consumer may receive (such as the number of visits to specialty physicians).
20
Q
Benefits package
A
the set of health care products and services covered by the contract between a managed care plan and the purchaser of care
21
Q
Board certified
A
describes the level of training and competency testing successfully completed by a physician.
22
Q
Brand-named drug
A
a drug that carries a specific, trademarked name and is produced by one manufacturer.
23
Q
Capitation
A
a system managed care plans use to pay physicians or hospitals, in which the providers receive a fixed, predetermined sum of money, typically on a monthly basis, from the plan to care for plan members
24
Q
Carve out
A
a product or service (such as prescription drug benefits or mental health care) provided by a managed care company that specializes in the particular service.
25
Case Management
process managed care plans may use to review the care that patients receive
26
Case Rate
a payment system in which the managed care plan pays health care providers an all-inclusive fee to provide care for a patient, based on the patient's diagnosis, or the medical treatments or surgical procedures provided to the patient.
27
Center of excellence
is a designation assigned by the managed care industry to provide hospitals or a network of hospitals selected to provide managed care plan for patients with a specific set of clinical services, such as transplants.
28
chronic care
supportive care for an ongoing or lengthy illness
29
chronic illness
any ailment that requires ongoing treatment and management, beyond its acute phase, sometimes for a lifetime.
30
Claims form
paperwork that patients and health care providers file with managed care plans in order to receive payment for services.
31
clinical pathway
a medical "roadmap" that helps health care providers identify the most appropriate course of treatment for a specific patient, based on that patient's clinical situation.
32
clinical trial
a medical research study in which physicians assess the effect of a new test or treatment versus an existing test or treatment or none at all.
33
closed panel
situation in which the physicians who work for a managed care plan see and treat only patients belonging to the plan.
34
coinsurance
the portion of health care costs not paid by the managed care plan, for which the consumer is responsible.
35
Contract
legal agreement between a managed care plan and either an employer or a consumer that describes the monthly premiums due to the plan, the health care services covered by the plan, and how much the plan is obligated to pay for each service.
36
contract year
the 12 month period covered by the agreement between the plan and the employer, consumer, or provider.
37
contracted provider
a hospital, physician, network of hospitals and physicians, or other health care providers who enter into a legal agreement with a managed care plan to care for the plan's members for negotiated prices.
38
coordination of benefits
a process that takes place between two or more managed care plans that cover the same consumer, to ensure that plans do not make duplicative or unnecessary payments for services.
39
copayment
a fixed sum of money that a consumer pays each time he or she receives a covered service from a plan contracted provider.
40
cost sharing
the responsibility of a consumer in a managed care plan to pay a portion of the costs for his or her care
41
cost based reimbursement
a payment system in which managed care plans pay health care providers based on the actual cost of a test or treatment provided to a plan member.
42
coverage
decision making process that identifies what services or products are benefits under the employer's or consumer's contract with the plan.
43
covered expenses
the costs of health care products or services that are eligible for payment by the managed care plan.
44
credentialing
a system used by managed care plans to assess the qualifications of physicians or other health care providers who may be offered contracts with the plan.
45
customer service
a resource available to the managed care plan member to answer member's questions, help resolve disputes or complaints, and explain plan operations.
46
deductible
a form of cost sharing in a managed care plan, in which a consumer pays a fixed dollar amount of covered expenses each year, before the plan begins paying its share of costs.
47
denial of care
a refusal by a managed care plan to cover a specific test or treatment.
48
direct contracting
the legal relationship between a managed care plan and an employer, in which the managed care plan agrees to provide a specific set of health care benefits for employees, for specified premiums.
49
discounted FFS
a payment system in which a managed care plan pays a health care provider a negotiated fee for each specific health care service, after the service is rendered to a plan member
50
Disease management
an organized, integrated program of health care and patient education aimed at providers or patients with a specific diagnosis, such as cancer or diabetes
51
Drug formulary
an exclusive list of drugs covered by a managed care plan.
52
drug utilization review
systematic oversight of prescription medicines used by managed care plans to assess costs, prescription patterns, and the appropriateness of drug therapy.
53
emergency care
urgent medical tests and treatment provided to patients with severe or life-threatening symptoms.
54
employer group health plan
package of medical benefits offered to all the employees at a company, typically using one or more managed care plans.
55
ERISA - Employee retirement income security act
a federal law that regulates the pension, health and welfare benefits offered by employers to their employees.
56
Evidence of coverage
a detailed description of the medical benefits available to a member of a managed care plan, most often provided to members after they enroll in the plan.
57
exclusion
a health care product or service which a managed care plan will not cover or pay for.
58
EOB
a statement sent to some managed care plan members from the plan that shows the following information: the actual charges levied by a health care provider for health care services provided to the plan
member, the plan's allowable charge for each service, the plan's payment for each service, and the amount owed by the plan member (coinsurance or deductible).
59
Fee schedule
a predetermined list of prices a managed care plan will pay for specific health care products or services given to plan members by health care providers.
60
FFS
reimbursement made by a managed care plan to a health care provider after the provider renders care to a plan member.
61
first dollar coverage
managed care plan benefits that do not require plan members to meet an annual deductible before plan coverage and payment begin.
62
Gag rules
: portions of contracts between managed care plans and physicians that may limit the communication between physicians and their patients
63
Gatekeeper
a primary care physician who controls a patient's access to certain tests, treatments, and specialty physicians in a managed care plan.
64
Generic Drug
a medicine that is the chemical equivalent of a brand-name drug.
65
Grievance
a complaint brought to the administration of a managed care plan by a plan member.
66
Group model HMO
a type of managed care plan in which the plan has contracted with a multispecialty physician group to care for plan members
67
Health care Financing administration
now called the Centers for Medicare and Medicaid Services (CMS), a federal agency that runs the Medicare and Medicaid programs.
68
Health care spending account
a benefit option offered by some employers that lets employees set aside a specific sum of money each year to pay for certain medical expenses, such as premiums, copayments, deductibles, and
coinsurance amounts, or services such as eyeglasses or dental care.
69
health education
programs or classes offered by some managed care plans to their members to help plan members enhance their understanding of specific issues, such as nutrition or contraception, or meet personal goals, such as smoking cessation, weight loss, or stress management.
70
Health insurance purchasing co-op
a mechanism in which individuals and small businesses join together to purchase medical benefits from managed care plans.
71
Health plan employer data information set
a set of managed care plan performance measures collected, organized, and reported by the National Committee for Quality Assurance (NCQA, see below).
72
Hospice care
supportive services provided to patients who have reached the terminal stage of their illness when aggressive, curative therapy is no longer appropriate.
73
hospital privileges
permission granted by a hospital to a physician to admit patients to the institution and manage their care while hospitalized
74
Indemnity insurance plan
type of health insurance that pays for care after consumers receive it, usually on a fee-for-service basis, with little oversight to assess the cost or appropriateness of care.
75
Independent practice association
a type of managed care plan which contracts with many physicians or physicians groups in an area to provide care to plan members.
76
Joint commission on the accreditation of healthcare organizations
a private, non-profit agency that evaluates and accredits managed care plans, hospitals, networks of health care providers, and other health care
entities.
77
Lifetime Cap
maximum dollar amount of benefits available to a consumer in a managed care plan.
78
Major Medical
health insurance benefits found most commonly in indemnity insurance plans that provide coverage and payment for services such as hospitalization, surgery, or durable medical equipment.
79
malpractice
negligent care provided to a patient by a health care provider or managed care plan that results in harm to the patient.
80
Managed Care
a broad term that describes the health insurance products available to most consumers in the health care marketplace today
81
Managed indemnity insurance
an indemnity insurance plan that incorporates some managed care features, such as utilization review, to help
control costs.
82
mandated benefits
products or services offered in managed care plans that are required by either federal or state law.
83
medicaid
a joint federal and state program that provides health insurance to low income persons who meet specific eligibility requirements.
84
medicaid HMO
a managed care plan approved by a state government to enroll persons eligible for Medicaid.
85
Medical director
the chief physician in a managed care plan who is part of the plan's administration, and oversees plan coverage decisions and the performance of the physicians who work for the plan or sign contracts to serve plan members.
86
medical licensing board
a state regulatory agency that authorizes physicians to practice in a state and disciplines physicians who are found to have violated the state's laws or regulations that govern the practice of
medicine.
87
medical loss ratio
the amount of money spent on medical care for plan members by a managed care plan
88
Medical record
the official documentation of the care provided to a patient by a health care provider
89
medical underwriting
the process by which a managed care plan evaluates the level of risk posed by an individual consumer or group of consumers, based upon age, sex, health history, or other factors.
90
medically necessary
health care products or services covered by the managed care plan that are appropriate and indicated to assist in the diagnosis or treatment of disease.
91
medicare
a federal health insurance program that provides medical benefits to all persons over age 65 who receive Social Security benefits or are disabled and meet specific eligibility requirements
92
medicare Hmo
a managed care plan that meets federal standards and is eligible to enroll persons who receive Medicare benefits.
93
medicare secondary payer
a circumstance in which a Medicare beneficiary has both Medicare and private insurance.
94
medigap
Medicare supplemental health insurance that pays for some of the deductibles and coinsurance for which Medicare beneficiaries are responsible.
95
mental health care
medical services, such as counseling or therapy, hospitalization, and prescription drugs, used to diagnose and treat emotional and psychological illness, such as depression, bipolar disorder, or substance
abuse.
96
mixed model or network HMO
a managed care plan that contracts with individual physicians, as well as physicians groups to provide care for plan members.
97
monthly premium
the amount paid each month to a managed care plan by an employer, employees, or individual consumers to obtain coverage from the plan.
98
morbidity rates
the frequency with which an illness occurs in a given population. Morbidity is usually expressed as the number of illnesses per 100,000 population.
99
mortality rates
the frequency of death from a given cause in a population. Mortality is usually expressed at the number of deaths per 100,000 population.
100
national committee for quality assurance
a private, nonprofit organization that evaluates and accredits managed care plans.
101
networks of health care providers
groups of hospitals, physicians, and other providers that come together to offer managed care plans and consumers an organized, comprehensive system of care.
102
ombudsman
a troubleshooter who can help managed care plan members resolve problems or complaints with the plan
103
open enrollment
a specific period of time (one or more times annually or monthly) during which consumers can select and enroll in, or disenroll from, a managed care plan.
104
open panel
a situation in which physicians care for patients from many different managed care plans, as well as other insurers, such as Medicaid and Medicare.
105
out of pocket expense
costs of health care products or services which managed care plan members pay themselves
106
outcome data
information that describes the result of care provided to managed care plan members
107
participating provider
a hospital or physician who signs a contract with a managed care plan and agrees to care for plan members for negotiated fees and conditions specified in the contract
108
payer
another term for an insurer that covers and pays for a specific set of health care benefits for plan members.
109
per member per month
refers to the incremental sum paid by a managed care plan to a health care provider who cares for plan members under a capitation arrangement.
110
pharmacy and therapeutics committee
a group of physicians, pharmacists, and other health care professionals within a managed care plan who review new drugs and biotechnology products to decide which ones the plan will cover, under what circumstances, and at what cost to the plan and its members.
111
Pharmacy benefit manager
a type of managed care plan that specializes in the distribution and management of prescription drugs for plan members.
112
Physician hospital organization
an entity formed by physicians and hospitals under the authority of state or federal law to negotiate and sign contracts with managed care plans or contract directly with employers to serve the health care needs of their employees.
113
plan member
a consumer or his or her dependent who enrolls in a managed care plan through an employer, the Medicare or Medicaid programs, or as an individual enrollee.
114
Point of service
the most rapidly expanding form of managed care in the marketplace.
115
practice guidelines
suggestions or mandates for how physicians can manage patients with a particular symptom or diagnosis to achieve the best possible outcome.
116
practice profiling
also known as practice evaluation; the process by which managed care plans measure how well physicians who treat plan members are performing against plandeveloped financial and clinical criteria.
117
pre-existing condition
a medical condition, ailment, or disease for which a managed care plan member was treated during a specific period of time before joining the plan, typically one or two years
118
preadmission certification
prior approval by a managed care plan to admit a member to hospital for medical treatment, testing, or surgery.
119
preauthorization
prior approval by a managed care plan for a plan member to receive a medical treatment, test, or surgical procedure on an outpatient basis.
120
PPO
a large group of hospitals and physicians under contract to a managed care plan
121
Premature Hospital discharge
termination of an inpatient hospital stay before it is medically appropriate to send the patient home.
122
preventative health care
health care products and services aimed at forestalling the development of illness or injury
123
PCP
a class of physicians that typically includes internists, family physicians, pediatricians, and obstetricians/gynecologists
124
Provider
a qualified, licensed professional (physician, dentist, optometrist, etc.) or institution (hospital, clinic, skilled nursing facility, etc.) that renders health care services to managed care plan members under a contract with a plan.
125
Quality Assurance
an oversight program used by health care providers and managed care plans to evaluate the care provided to plan members and identify and rectify problems in care delivery.
126
Referral
authorization by a managed care plan or primary care physician for a plan member to use other services in the plan, such as diagnostic tests, care from a specialist, or physical therapy.
127
report card
information on how well a managed care plan performs compared to other managed care plans, or national standards, along specific clinical, financial, or consumer satisfaction criteria
128
screening tests
health care services intended to identify diseases at an early stage of development when they are typically easier and less costly to treat
129
Secondary payer
a second plan a consumer has. Through coordination of benefits (see above), the second plan will pay for covered services that are not covered and paid for by the first plan.
130
shared financial risk
a concept in which health care providers, through payment arrangements with managed care plans such as capitation (see above), share risk on the health care services they provide to managed care plan members
131
specialist
physician who has received extensive training (beyond that of a primary care physician) in a specific, often highly focused area of medicine.
132
staff model HMO
a type of managed care plan in which physicians who care for plan members are employees of the plan.
133
state insurance commissioner
a regulatory official who enforces the state insurance laws and regulations to which managed care plans are subject
134
stop loss insurance
a type of back-up insurance that limits financial risk for physicians or hospitals who accept capitation payments to care for managed care plan members.
135
symptom
manifestation of a disease or illness that a patient expresses to a physician or other health care provider, such as pain, nausea, or dizziness.
136
technology assessment
process that managed care plans use to evaluate new tests, treatments, drugs, medical devices, biotechnology products, and surgical procedures, to decide what the plan will cover, for which patients, and at what costs to the plan and planmembers.
137
therapeutic substitution
replacement of a drug prescribed by a physician with a similar or equivalent product, usually with permission of the prescribing physician.
138
Third Party Administrator
a managed care plan or other health insurer that processes claims, pays bills, and manages contracts with health care providers for self-insured health plans.
139
Triage
a system by which managed care plans or health care providers prioritize patients to ensure that patients with the greatest need receive care first.
140
Usual, customary reasonable charges
a calculation by a managed care plan of what it believes is the appropriate fee to pay for a specific health care product or service, in the geographic area in which the plan operates.
141
Utilization review
a mechanism of assessing the care received by a patient in a managed care plan to assess whether the care is medically necessary and appropriate to the patient's needs.
142
Withhold
portion of the fees paid to health care providers by managed care plans that are held back by the plan until the end of the contract year
