question

accreditation

answer

a 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.

question

adverse selection

answer

members who are sicker than the general population

question

Amendment to the HMO Act of 1973

answer

allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be partially reimbursed

question

cafeteria plan

answer

is usually offered either by a single insurance plan or as a joint venture among two or more insurance carriers, provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans. It is also called a cafeteria plan or flexible benefit plan because of the different benefit plans and extra coverage options provided through the insurer or third-party administrator. Triple actions plans are intended to prevent the problem of covering members who are sicker than the general population (called adverse selection),

question

capitation

answer

pre-established payments for providing health care services to enrolees over a period of time (usually 1 yr.) Physician either profits or loses money)

question

case management

answer

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

question

case manager

answer

submits written confirmation, authorizing treatment to the provider

question

closed-panel HMO

answer

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

question

competitive medical plan (CMP)

answer

an HMO that meets federal eligibility requirements for a Medicare risk contract, but is not licensed as a federally qualified plan.

question

concurrent review

answer

review for medical necessity of tests and procedures ordered during an inpatient hospitilization

question

consumer-driven health plan (CDHP)

answer

define employer contributions and ask employees to be more responsible for health care decisions and cost-sharing

question

customized sub-capitation plan (CSCP)

answer

health care expenses are funded by insurance coverage; the individual selects one of each type of provider to create a custommized 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 (sub-capitation payment)

question

direct contract model HMO

answer

contracted health care services are delivered to subscribers by individual physicians in the community

question

discharge planning

answer

involves arranging appropriate health care services for the discharged patient

question

enrollees

answer

employees & dependents; known as beneficiaries in privable insurance plans

question

exclusive provider organization (EPO)

answer

a managed care plan that provides benefits to subscribers if they receive services from network providers. A network providers is a physician or health care facility under contract to the managed care plan.

question

external quality review organization (EQRO)

answer

Many states have enacted legislation requring EQROs to review health care provided by managed care organizations. The types of quality reviews performed include government oversight, patient satisfaction surveys, data collected from grievance proceudres, and reviews conducted by independent organizations. Independent organizations that perform reviews include accrediation agencies such as the National committee for Quality Assurance and Joint Commission on Accreditation of Healthcare Organizations.

question

federally qualified HMO

answer

certified to provide health care services to Medicare and Medicaid enrollees as one that has applied for and met federal standards established in the HMO Act of 1973

question

fee-for-service

answer

reimbruse providers for individual health care services rendered

question

flexible benefit plan

answer

is usually offered either by a single insurance plan or as a joint venture among two or more insurance carriers, provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans. It is also called a cafeteria plan or flexible benefit plan because of the different benefit plans and extra coverage options provided through the insurer or third-party administrator. Triple actions plans are intended to prevent the problem of covering members who are sicker than the general population (called adverse selection),

question

flexible spending account (FSA)

answer

tax exempt accounts 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 deposed (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax free money can be withdrawn for purposed other than health care expenses after payment of income tax plus a 15% penalty unused balances "roll over" from year to year, and if an employee changes jobs, he or she can continue to use the FSA to pay for qualified health care expenses

question

gag clause

answer

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

question

gatekeeper

answer

provides essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists. Used by primary care providers.

question

group model HMO

answer

contracted health care services are delivered to subscribers by participating physicians who are members of an independent multispecialty group practice. The HMO reimburses the physican group, which is then responsible for reimbursing physician members and contracted health care facilities (e.g. hospitals). The physician group can be owned or managed by the HMO, or it can simply contract with the HMO.

question

group practice without walls (GPWW)

answer

establishes a contract that allows physicians to maintain their own offices and share service (e.g. appointment scheduling and billing)

question

health care reimbursement arrangement (HCRA)

answer

tax exempt account used to pay for health care expenses - individual decides, in advance, how much money to deposit in HCRS (unused funds are lost)

question

health reimbursement arrangement (HRA)

answer

tax exempt accounts offered by employees with more than 50 employees, which individuals use to pay health care bills United States Treasury Department and IRS issued a tax guidance for HRAs in 2002 Must be used for qualified health care expenses, require enrollment in a high-duductible insurance policy and accumulate money for future years If an employee changes jobs, he or she can continue to use the HRA to pay for qualified health care expenses

question

health savings account (HSA)

answer

tax exempt accounts 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 deposed (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax free money can be withdrawn for purposed other than health care expenses after payment of income tax plus a 15% penalty unused balances "roll over" from year to year, and if an employee changes jobs, he or she can continue to use the FSA to pay for qualified health care expenses

question

health savings security account (HSSA)

answer

tax exempt accounts 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 deposed (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax free money can be withdrawn for purposed other than health care expenses after payment of income tax plus a 15% penalty unused balances "roll over" from year to year, and if an employee changes jobs, he or she can continue to use the FSA to pay for qualified health care expenses

question

independent practice association (IPA) HMO

answer

contracted health services are delivered to subscribers by physicians who remain in their independent office settings. The IPA is an intermediary (e.g. physician association) that negotiates the HMO contract and receives and manages the capitation payment from the HMO, so that physicians are paid on either a fee-for-service or capitation basis.

question

individual practice association (IPA) HMO

answer

contracted health services are delivered to subscribers by physicians who remain in their independent office settings. The IPA is an intermediary (e.g. physician association) that negotiates the HMO contract and receives and manages the capitation payment from the HMO, so that physicians are paid on either a fee-for-service or capitation basis.

question

integrated delivery system (IDS)

answer

an organization of affiliated providers' sites (e.g. hospitals, ambulatory surgical centers, or physician groups) that offer joint health care services to subscribers. Models include physician-hospital organizations, management service organizations, group practices without walls, integrated provider organizations, and medical foundations.

question

integrated provider organization (IPO)

answer

manages the delivery of health care services offered by hospitals, physicians (who are employees of IPO) and other health care organizations (e.g., an ambulatory surgery clinic and a nursing facility)

question

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

answer

provides voluntary accreditation of a variety of health care organizations (e.g. hospitals, long-term care and ambulatory care facilities)

question

legislation

answer

laws

question

managed care organization (MCO)

answer

responsible for the health of a group of enrolles, and can be a health plan, hospital, physician group, or health system

question

managed health care (managed care)

answer

developed as a way to provide affordable, comprehensive, prepaid health care services to enrollees (employees & dependents; known as beneficiaries in private insurance plans). Managed care is financed thru capitation.

question

management service organization (MSO)

answer

usually owned by physicians or a hospital and provides practice management (administrative and support) services to individual practices.

question

mandate

answer

laws

question

medical foudation

answer

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

question

medical savings account (MSA)

answer

allows individuals to withdraw tax-free funds for health care expenses that are not covered by a qualifying high-deductible health plan.

question

Medicare + Choice (Medicare Part C)

answer

expanded Medicare coverage options by creating managed care plans, to include HMOs, PPOs and MSAs.

question

Medicare risk program

answer

allows federally qualified HMOsd and competitive medical plans that met specified Medicare requiements to provide Medicare covered services under a risk contract

question

National Committee for Quality Assurance (NCQA)

answer

reviews managed care plans and develops report cards to allow health care consumers to make informed decisions when selecting a plan.

question

network model HMO

answer

contracted health care services are provided to subscribers by two or more physicians multi-specialty grou practices

question

network provider

answer

a physician or health care facility under contract to the managed care plan

question

Office of Managed Care

answer

facilitated innovation and completion among Medicare HMOs

question

open-panel HMO

answer

Health care is 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

question

physician incentive plan

answer

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.

question

physician incentives

answer

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) so as to save money for the managed care plan.

question

physician-hospital organization (PHO)

answer

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.

question

point-of-service plan (POS)

answer

patients have freedom to use the HMO panel of providers or to self-refer to non-HMO providers

question

preadmission certification (PAC)

answer

or preadmission review - review for medical necessity of inpatient care prior to the patient's admission.

question

preadmission review

answer

or PAC) - review for medical necessity of inpatient care prior to the patient's admission.

question

Preferred Provider Health Care Act of 1985

answer

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

question

preferred provider organiation (PPO)

answer

a 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. Premiums, deductibles, and copayments are usually higher than those paid for HMOs, but lower than regular fee-for-service plan.

question

primary care provider (pcp)

answer

responsible for supervising and coordinating health care services for enrollees, and approves referrals to specialists and inpatient hospital admissions (except in emergencies)

question

quality assessment and performance improvement (QAP)

answer

quality assurance activities are performed to improve the functioning of M + C organizations

question

quality assurance program

answer

includes activities that assess the quality of care provided in a health care setting

question

Quality Improvement System for Managed Care (QISMC)

answer

Medicare established (QISMC) to ensure the accountability of managed care plans in terms of objective, measurable standards (requirements). Plans are required to meet minimum performance levels and to share demonstrable and measurable improvements in specified broad clinical areas (e.g. preventive services, acute ambulatory care, chronic care, and hospital care) based on performance improvement projects that each plan identifies.

question

report card

answer

containsdata regarding a managed care plan's quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control

question

retrospectively

answer

conducted after care has been administered.

question

risk contract

answer

an arrangement among providers to provide capitated (fixed, prepaid basis) health care services to Medicare beneficiaries

question

risk pool

answer

is 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

question

second surgical opinion (SSO)

answer

a second physician is asked to evaluate the necessity of surgery, and recomment the most economic appropriate facility in which to perform the surgery (e.g. outpatient clinic or doctor's office versus inpatient hospitalization)

question

self-referral

answer

when an enrollee sees a non-HMO panel specialist without a referral from the primary care physician. The enrollee will have greater out-of-pocket expenses, as the enrollee must pay both a large deductible and 20 - 25% coinsurance charges, similar to those paid by persons with fee-for-service-plans.

question

staff model HMO

answer

health care services are provided to subscribers by physicians employed by the HMO. Premiums and other revenue are paid to the HMO. Usually, all ambulatory services are provided within HMO corporate buildings

question

standards

answer

requirements

question

survey

answer

evaluation

question

triple option plan

answer

is usually offered either by a single insurance plan or as a joint venture among two or more insurance carriers, provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans. It is also called a cafeteria plan or flexible benefit plan because of the different benefit plans and extra coverage options provided through the insurer or third-party administrator. Triple actions plans are intended to prevent the problem of covering members who are sicker than the general population (called adverse selection),

question

utilization management (utilization review)

answer

is a method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care or retrospectively. Utilization management activities are performed by managed care plans and include, preadmission review, preauthorization, concurrent review, and discharge planning.

question

utilization review organization (URO)

answer

Some managed care plans contract out with management services to a URO - an entity that establishes a utilization program and performs external utilization review services. Other plans contract with a third party administrator.

question

Health Plan Employer Data and Information set HEDIS)

answer

sponsored by the National Committee for Quality Assurance, consists of performance measures used to evaluate managed care plans (e.g. rate of Pap smears performed among women of a certain age)

question

third party administrators (TPA)

answer

an organization that provides health benefits clams administration and other outsourced services for self-insurance companies

Understanding Health Insurance – week 3 – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards