Lesson 3 Flashcards
Managed health care
Managed care. Is a health care delivery system organized to manage cost, utilization and quality.
Managed care organization (MCO)
Is responsible for the health of a group of enrollees and Can be a health plan, hospital, physician group or health system.
Fee-for-service
Plan which reimbursed providers for Individual health care services rendered.
Capitation
Where providers accept preestablished payments for providing health care services to enrollees over a period of time. (Usually a year)
Primary care provider (PCP)
Responsible for supervising and coordinating health care services for enrollees and approves referrals to specialists.
Quality assurance program
Includes activities that assess the quality of care provided in a health care setting.
External quality review organization (EQRO)
Reviews health care provided by managed care organizations.
Quality improvement system for managed care (QISMC)
Ensures the accountability of managed care plans in terms of objective, measurable standards.
Utilization review organization (URO)
An entity that established a utilization management program and performs external utilization review services.
Gag clauses
Prevents providers from discussing all treatment options with patients
Exclusive provider organization (EPO)
A managed care plan that provides benefits to subscribers who are required to receive service from network providers.
Network provider
A physician or health care facility under contract to the managed care plan.
Integrated delivery system (IDS)
Is an organization of affiliated providers sites that offer joint health care services to subscribers.
Physician-hospital organization (PHO)
Is owned by the hospitals. And physician groups that obtain managed care plan contracts. Physicians maintain their own practices and provide health care services to plan members.
Management service organization (MSO)
Is usually owned by physicians or a hospital and provided practice management (administrative and support) services to individual physician practices.
