Managed Care and Integrated Organizations Flashcards
Medical loss ration
Percent of premium revenue spent on medical expenses. Remainder is used for administration, marketing, and profits.
Fee Schedule
Provider bills services separately but is paid according to a pre-negotiated schedule
Panel
A physician who has formal affiliations with an MCO is said to be on the panel of the MCO
Closed-panel
Services obtained from providers outside the panel are not covered by the plan
Open-panel
Allows access to providers outside the panel, but enrollees almost always have to pay higher out of pocket costs
Case management
Organized approach to evaluating and coordinating care, particularly for complex medical issues.
Disease management
Population oriented strategy for people with chronic conditions.
Utilization Review
Process of evaluating the appropriateness of services provided
Prospective utilization review
Determines appropriateness of utilization before care is actually delivered
Concurrent utilization review
Determines on a daily basis the length of stay needed in a hospital
Retrospective utilization review
A review of utilization after services are delivered
Discharge planning
Part of treatment plan from outset and focuses on post discharge continuity of care.
Practice profiling
Development of physician-specific practice patterns and the comparison of individual practice patterns to some norm.
HMO differences
Offers preventive care, usually requires choosing a PCP who acts as a gatekeeper, provider receives a capitated fee, all health care has to be in network, HMO complies with established standards of quality
Mixed model
Can not be categorized into any of the 4 models
