MANAGED HEALTH CARE

Question 1

Primary care providers (PCP)

Answer 1

• 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

Question 2

Quality Assurance

Answer 2

A program that can assess the quality of care provided in a health care setting.

Question 3

Utilization management

Answer 3

A method of controlling health care costs and quality care by reviewing the appropriateness and necessity of care.

Question 4

Case management

Answer 4

Involves development of patient care plans for the coordination and provision of care for complicated cases in a cost- effective manner.

Question 5

EPO

Answer 5

Exclusive Provider Organization

Question 6

IDS

Answer 6

Integrated Delivery systems

Question 7

HMO

Answer 7

Health Maintenance Organization

• A PCP is assigned to each subscriber

Question 8

PPO

Answer 8

Preferred Provider Organization

-Open ended plans all patients to use non-PPO providers in exchange for larger out of pocket expenses.

Question 9

Consumer Directed Health Plans

Answer 9

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

Question 10

Health maintenance Organization (HMO)

Answer 10

Responsible for providing health care services to subscribers in a given geographical area for a fixed fee.

Question 11

Occupational Safety and Health Administration Act of 1970 ( OSHA)

Answer 11

Legislation designed to protect all employees against injuries from occupational hazards in the workplace.

Question 12

Major Medical Insurance

Answer 12

Coverage for catastrophic or prolonged illnesses and / or injury

Question 13

Preferred Provider Organization (PPO)

Answer 13

Is a network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations

Question 14

Integrated Delivery System (IDS)

Answer 14

An organization of affiliated providers sites that offer joint health care services to its subscribers

Question 15

Preauthorization

Answer 15

• a review for medical necessity of tests and procedures ordered

Question 16

SSO

Second Surgical Opinion

Answer 16

a second physician is asked to evaluate the necessity of surgery and to recommend the most economic appropriate facility to perform the surgery ( outpatients facility vs. doctors office )