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Chapter 3
Managed Health Care
84
Health Care
08/22/2010

Additional Health Care Flashcards

 


 

Cards

Term
utilization management (utilization review)
Definition
method of con¬trolling health care costs and quality of care by review¬ing the appropriateness and necessity of care provided to patients prior to the administration of care
Term

utilization review organization (URO) 

Definition
entity that estab­lishes a utilization management program and performs external utilization review services.
Term

enrollees

Definition
also called covered lives; employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans
Term

customized sub-capitation plan (CSCP)

Definition
managed care plan in which health care expenses are funded by insurance coverage; the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium; each provider is paid a fixed amount per month to pro­vide only the care that an individual needs from that provider (called a sub-capitation payment).
Term
CSCP
Definition
customized sub-capitation plan
Term

direct contract model HMO

Definition
contracted health care services delivered to subscribers by individual physi­cians in the community.
Term

discharge planning

Definition
involves arranging appropriate health care services for the discharged patient (e.g., home health care).
Term

exclusive provider organization (EPO)

Definition
managed care plan that provides benefits to subscribers if they receive services from network providers.
Term
EPO
Definition

exclusive provider organization

Term

external quality review organization (EQRO)

Definition
responsible for reviewing health care provided by managed care organizations.
Term
EQRO
Definition
external quality review organization
Term

federally qualified HMO

Definition
certified to provide health care services to Medicare and Medicaid enrollees.
Term
fee-for-service
Definition
reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services (e.g., brand-name vs. generic pre¬scription medication
Term

flexible spending account (FSA)

Definition
tax-exempt account offered by employers with any number of employees, which individuals use to pay health care bills; par­ticipants enroll in a relatively inexpensive, high-deductible insurance plan, and a tax-deductible sav­ings account is opened to cover current and future medical expenses; money deposited (and earnings) is tax-deferred, and money is withdrawn to cover quali­fied medical expenses tax-free; money can be with­drawn for purposes other than health care expenses after payment of income tax plus a 15 percent penalty; unused balances "roll over" from year to year, and if an employee changes jobs, the FSA can continue to be used to pay for qualified health care expenses; also called health savings account (HSA) or health savings security account (HSSA).
Term
FSA
Definition
flexible spending account
Term

gag clause

Definition
prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.
Term

gatekeeper

Definition
primary care provider for essential health care services at the lowest possible cost, avoiding non-essential care, and referring patients to specialists.
Term

group model HMO

Definition
contracted health care services delivered to subscribers by participating physicians who are members of an independent multispecialty group practice.
Term

group practice without walls (GPWW)

Definition
contract that allows physicians to maintain their own offices and share services (e.g., appointment scheduling and billing).
Term
GPWW
Definition
group practice without walls
Term

health care reimbursement account (HCRA)

Definition
tax-exempt account used to pay for health care expenses; individ­ual decides, in advance, how much money to deposit in an HCRA (and unused funds are lost).
Term
HCRA
Definition
health care reimbursement account
Term

health reimbursement arrangement (HRA)

Definition
tax-exempt accounts offered by employers with more than 50 employees; individuals use HRAs to pay health care bills; HRAs must be used for qualified health care expenses, require enrollment in a high-deductible insurance policy, and can accumulate unspent money for future years; if an employee changes jobs, the HRA can continue to be used to pay for qualified health care expenses.
Term
HRA
Definition

health reimbursement arrangement

Term

independent practice association (IPA) HMO

Definition

also called individual practice association (IPA); type of HMO where contracted health services are delivered to sub­scribers by physicians who remain in their indepen­dent office settings.

Term
IPA
Definition
independent practice association
Term

integrated delivery system (IDS)

Definition
organization of affili­ated provider sites (e.g., hospitals, ambulatory surgical centers, or physician groups) that offer joint health care services to subscribers.
Term
IDS
Definition

integrated delivery system

Term

integrated provider organization (IPO)

Definition
manages the delivery of health care services offered by hospitals, physicians employed by the IPO, and other health care organizations (e.g., an ambulatory surgery clinic and a nursing facility).
Term
IPO
Definition
integrated provider organization
Term

managed care organization (MCO)

Definition
responsible for the health of a group of enrollees; can be a health plan, hospital, physician group, or health system.
Term
MCO
Definition

managed care organization

Term
managed health care (managed care)
Definition
combines health care delivery with the financing of services provided.
Term
management service organization (MSO) 
Definition
usually owned by physicians or a hospital and provides practice management (administrative and support) services to individual physician practices.
Term
MSO
Definition
management service organization 
Term

mandate

Definition
laws
Term

legislation

Definition
laws
Term
medical savings account (MSA)
Definition
tax-exempt trust or custodial account established for the purpose of paying medical expenses in conjunction with a high-deductible health plan; allows individuals to withdraw tax-free funds for health care expenses, which are not covered by a qualifying high-deductible health plan.
Term
MSA
Definition
medical savings account
Term

medical foundation

Definition
nonprofit organization that con­tracts with and acquires the clinical and business assets of physician practices; the foundation is assigned a provider number and manages the practice's business.
Term

Office of Managed Care

Definition
CMS agency that facilitates innovation and competition among Medicare HMOs.
Term
open-panel HMO
Definition
health care provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO.
Term
National Committee for Quality Assurance (NCQA)
Definition
a private, not-for-profit organization that assesses the quality of managed care plans in the United States andreleases the data to the public for its consideration when selecting a managed care plan.
Term
network model HMO
Definition
contracted health care services provided to subscribers by two or more physician mul-tispecialty group practices
Term
network provider
Definition
physician or health care facility under contract to the managed care plan.
Term

quality assessment and performance improvement (QAPI)

 

Definition
program implemented so that quality assurance activities are performed to improve the functioning of Medicare Advantage organizations.
Term
QAPI
Definition
quality assessment and performance improvement
Term

quality assurance program

Definition
activities that assess the quality of care provided in a health care setting.
Term

Quality Improvement System for Managed Care (QISMC)

Definition

established by Medicare to ensure the accountability of managed care plans in terms of objective, measur­able standards.

Term
QISMC
Definition
Quality Improvement System for Managed Care
Term

physician incentive plan

Definition
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.
Term

physician incentives

Definition
include payments made directly or indirectly to health care providers to serve as encouragement to reduce or limit services (e.g., dis­charge an inpatient from the hospital more quickly) to save money for the managed care plan.
Term

physician-hospital organization (PHO)

Definition
owned by hospital(s) and physician groups that obtain managed care plan contracts; physicians maintain their own practices and provide health care services to plan members.
Term
PHO
Definition

physician-hospital organization

Term

point-of-service plan

Definition
delivers health care services using both an HMO network and traditional indemnity coverage so patients can seek care outside the HMO network.
Term
preadmission certification (PAC)
Definition
review for medical neces¬sity of inpatient care prior to the patient's admission.
Term
PAC
Definition
preadmission certification
Term

preadmission review

Definition
review for medical necessity of inpatient care prior to the patient's admission.
Term

Preferred Provider Health Care Act of 1985

Definition
eased restric­tions on preferred provider organizations (PPOs) and allowed subscribers to seek health care from providers outside of the PPO.
Term

preferred provider organization (PPO) 

Definition
network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee.
Term
PPO
Definition
preferred provider organization
Term

primary care provider (PCP)

Definition
responsible for super­vising and coordinating health care services for enrollees and preauthorizing referrals to specialists and inpatient hospital admissions (except in emergencies).
Term

PCP

Definition
primary care provider
Term

prospective review

Definition
reviewing appropriateness and necessity of care provided to patients prior to admin­istration of care.
Term
triple option plan
Definition
usually offered by either a single insurance plan or as a joint venture among two or more insurance carriers, and provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans; also called cafeteria plan or flexible benefit plan.
Term

report card 

Definition
contains data regarding a managed care plan's quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control.
Term

retrospective review

Definition
reviewing appropriateness and necessity of care provided to patients after the admin­istration of care.
Term

risk contract

Definition
an arrangement among providers to provide capitated (fixed, prepaid basis) health care services to Medicare beneficiaries.
Term
risk pool
Definition
created when a number of people are grouped for insurance purposes (e.g., employees of an organization); the cost of health care coverage is determined by employees' health status, age, sex, and occupation.
Term

second surgical opinion (SSO)

Definition
second physician is asked to evaluate the necessity of surgery and recom­mend the most economical, appropriate facility in which to perform the surgery (e.g., outpatient clinic or doctor's office versus inpatient hospitalization).
Term
SSO
Definition
second surgical opinion
Term

accreditation

Definition
voluntary process that a health care facility or organization (e.g., hospital or managed care plan) undergoes to demonstrate that it has met stan­dards beyond those required by law.
Term
adverse selection
Definition
covering members who are sicker than the general population.
Term
Amendment to the HMO Act of 1973
Definition
legislation that allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be par¬tially reimbursed.
Term
cafeteria plan
Definition
also called triple option plan; provides different health benefit plans and extra coverage options through an insurer or third-party administrator.
Term
capitation
Definition
provider accepts preestablished payments for providing health care services to enrollees over a period of time (usually one year).
Term

case management

Definition
development of patient care plans to coordinate and provide care for complicated cases in a cost-effective manner.
Term

case manager 

Definition
submits written confirmation, authoriz­ing treatment, to the provider.
Term

Closed-panel HMO

Definition
health care is provided in an HMO-owned center or satellite clinic or by physicians who belong to a specially formed medical group that serves the HMO.
Term
competitive medical plan (CMP)
Definition
an HMO that meets federal eligibility requirements for a Medicare risk contract, but is not licensed as a federally qualified plan.
Term
CMP
Definition
competitive medical plan
Term
concurrent review
Definition
review for medical necessity of tests and procedures ordered during an inpatient hos-pitalization.
Term
URO
Definition
utilization review organization
Term
subscribers (policyholders)
Definition
person in whose name the insurance policy is issued