MB500 Flashcards
Case Manager
Submits written confirmation, authorizing treatment to the provider; coordinate healthcare services to improve patient outcomes while considering financial implications
continuity of care
documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment
deductible
amount for which the patient is financially responsible before an insurance policy provides reimbursement (to the provider)
health maintenance organization
responsible for providing health care services to subscribers in a given geographical area for a fixed fee
Healthcare Effectiveness Data and Information Set
created standards to assess managed care systems using data elements that are collected evaluated and published to compare the performance of managed health care plans
National Committee for Quality Assurance
a private not for profit organization that assesses the quality of managed care plans in the united state and releases the data to the public for their own consideration when selecting a managed care plan
physician incentives
requires managed care plans that contract with medicare or medicaid to disclose information about physician incentive plans to CMS or state medicaid agencies before a new or renewed contract receives final approval
point of service plan
delivers health care services using both managed care networks and traditional indemnity coverage so patients can seek care outside the managed care network
preferred provider organization
network of physicians, other health care practitioners and hospitals that have joined together to contract with insurance companies employers or other organizations to provide healthcare to subscribers for a discounted fee
preventative services
designed to help individuals avoid problems with health and injuries
Primary Care Provider
responsible for coordinating and supervising health care service for enrollees and pre authorizing referrals to specialists and inpatient hospital admissions (except for emergencies)
quality assurance program
activities that assess the quality or care provided in a healthcare setting
second surgical opinion
second physician is asked to evaluate the necessity of a surgery and recommend the most economical appropriate facility which to perform the surgery
utilization review
entity that establishes utilization management program and performs external utilization review services
Open Panel HMO
provides healthcare by individuals who are not employees of the hmo or who do not belong to a specifically formed medical group that serves the hmo
