MANAGED HEALTH CARE Flashcards
Primary care providers (PCP)
- Also known as the gatekeeper
- Supervises and coordinates health care services for enrollees
- approves referrals to specialists and inpatient hospital admissions except in the case of an emergency
Quality Assurance
A program that can assess the quality of care provided in a health care setting.
Utilization management
A method of controlling health care costs and quality care by reviewing the appropriateness and necessity of care.
Case management
Involves development of patient care plans for the coordination and provision of care for complicated cases in a cost- effective manner.
EPO
Exclusive Provider Organization
IDS
Integrated Delivery systems
HMO
Health Maintenance Organization
- A PCP is assigned to each subscriber
PPO
Preferred Provider Organization
-Open ended plans all patients to use non-PPO providers in exchange for larger out of pocket expenses.
Consumer Directed Health Plans
Flexible spending amount (FSA) tax exempt account offered by employers with any number of employees which individuals use to pay health care bills by contributing funds ( unspent funds are forfeited
Health maintenance Organization (HMO)
Responsible for providing health care services to subscribers in a given geographical area for a fixed fee.
Occupational Safety and Health Administration Act of 1970 ( OSHA)
Legislation designed to protect all employees against injuries from occupational hazards in the workplace.
Major Medical Insurance
Coverage for catastrophic or prolonged illnesses and / or injury
Preferred Provider Organization (PPO)
Is a network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations
Integrated Delivery System (IDS)
An organization of affiliated providers sites that offer joint health care services to its subscribers
Preauthorization
- a review for medical necessity of tests and procedures ordered
