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Managed Health Care

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Combines health care delivery with the financing of services provided.

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Consumer-directed Health Plans (CDHP)

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Provide incentives for controlling healthcare expenses and give individuals an alternative to traditional health insurance and managed care coverage. (Define employer contributions and ask employees to be more responsible for health care decisions and cost-sharing.)

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Enrollees

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(suscribers or policyholders) Employees and dependants who join a managed care plan; known as beneficiaries in private insurance plans.

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Medicare Risk Programs

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Allowed federally qualified HMOs and competitive medical plans that met specified Medicare requirements to provide Medicare covered services under a risk contract.

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Risk contract

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

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Competitive Medical Plan (CMP)

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An HMO that meets federal eligibility requirements for a Medicare risk contract but is not licenses as a federally qualified plan.

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Medical Savings Account (MSA)

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Allows individuals to withdraw tax-free funds for health care expenses that are not covered by qualifying high-deductible health plan. Healthcare expenses that may be reimbursed from the MSA include the following: Dental expenses, including uncovered orthodontia Eye exams, contact lenses, and eyeglasses Hearing care expenses Health plan deductibles and copayments Prescription drugs The MSA was replaced in 2003 with Health savings accounts (HSAs)

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Medicare+Choice

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

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Managed Care Organization (MCO)

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

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Fee-for-service Plan

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This reimburses providers for individual health care services rendered.

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Capitation

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Providers accept preestablished payments for providing health care services to enrollees over a period of time (usually one year).

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Primary Care Provider (PCP)

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

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Quality Assurance Program

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

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Report Card

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

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Utilization Management

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(Utilization Review) 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 after care has been provided.

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Prospective Review

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Prior to the administration of care.

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Retrospective Review

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After care has been provided.

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Preadmission Certification (PAC)

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(Preadmission Review) A review for medical necessity of inpatient care prior to the patient's admission.

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Preauthorization

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A review that grants prior approval for reimbursement of a health care service (e.g., elective surgery)

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Concurrent review

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A review for medical necessity of tests and procedures ordered during an inpatient hospitalization.

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Discharge planning

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

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Utilization Review Organization (URO)

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

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Case Management

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Involves the development of patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner. Case manager submits written confirmation, authorizing treatment, to the provider.

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Second Surgical Opinion (SSO)

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When a second physician is asked to evaluate the necessity of surgery and recommends the most economic, appropriate facility in which to perform the surgery.

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Gag clauses

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

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Physician incentives

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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.

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Federal Physician incentive plan

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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.

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Exclusive Provider Organization (EPO)

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A managed care plan that provides benefits to subscribers who are required to receive services from network providers.

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Network provider

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A physician or health care facility under contract to the managed care plan. Usually sign exclusive contracts with with the EPO which means they cannot contract with other managed care plans.

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Integrted Delivery System (IDS)

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An organization of affiliated providers' sites (e.g., hospitals, ambulatory surgical centers, or physician groups) that offer joint health care services to subscribers.

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Physician-hospital Organization (PHO)

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(IDS) 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.

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Management Service Organization (MSO)

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

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Group practice without walls (GPWW)

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(IDS) Estabslishes a contract that allows physicians to maintain their own offices and share services (e.g., appointment scheduling and billing)

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Integrated provider organization (IPO)

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

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Medical foundation

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(IDS) A nonprofit organization that contracts with and acquires the clinical and business assets of physician practices.

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Health Maintenance Organization (HMO)

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An alternative to traditional group health insurance coverage and provides comprehensive health care services to voluntarily enrolled members on a prepaid basis.

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Point-of-service plan (POS)

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Implemeted by some HMOs and PPOs. Provides patients the freedom to use the HMO panel of providers or to self-refer to non-HMO providers.

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Self-referral

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When a insurance enrollee sees a non-HMO panel specialist without a referral from the primary care physician. Results in a greater out-of-pocket expense, as he must pay both a larger deductible and a larger coinsurance charge.

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Preferred Provider Organization (PPO)

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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.

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Triple Option Plan

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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. 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. These plans are intended to prevent the problem of coveraing members who are sicker than the general population (adverse selection).

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Risk Pool

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This 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.

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Sub-capitation payment

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Each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider.

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Accreditation

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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.

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Survey

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Evaluation process that is conducted both offsite (e.g., managed care plan submits an initial document for review) and onsite (at the managed care plan's facilities).

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National Committee for Quality Assurance (NCQA)

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A private, not-for-profit organization that assesses the quality of managed care plans in the United States and releases the data to the public for consideration when selecting a mananaged care plan. Began accrediting managed care programs in 1991 when a need for consistent, independent information about the quality of care provided to patients was originally identified.

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Preferred Provider Health Care Act of 1985

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Eased restrictions on preferred provider organizaitons (PPOs) - Allowed subscribers to seek health care from providers outside of the PPO

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Amendment of the HMO Act of 1973

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

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Healthcare Effectiveness Data and Information Set (HEDIS)

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Created sstandards to assess managed-care systems in terms of membership, utilization of services, quality, access, health plan management and activities, and financial indicators

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HCFA's Office of Managed Care

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Facilitated innovation and competitio among Medicare HMOs

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External Quality Review Organizations (EQRO)

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Mandated by legislation in many states. Reviews health care provided by managed care organizations. Types of quality reviews performed include government oversight, patient satisfaction surveys, data collected from griebance procedures, and reviews conducted by independent organizations.

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Quality Improvement System for Managed Care (QISMC)

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Established by Medicare to ensure the accountability of managed care plans in terms of objective, measurable standards (requirements)

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Health Plan Employer Data and Information Set (HEDIS)

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Performance measures used to evaluate managed care plans. Sponsered by the National Committee for Quality Assurance (NCQA)

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National Committee for Quality Assurance (NCQA)

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

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Third-Party Administrator (TPA)

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An organization that provides health benefits claims administration and other outsourced services for self-insured companies.

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adverse selection

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cafeteria plan

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closed-panel HMO

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customized sub-capitation plan (CSCP)

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direct contact model HMO

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federally qualified HMO

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flexible benefit plan

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flexible spending account (FSA)

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gatekeeper

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group model HMO

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healthcare reimbursement account (HCRA)

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Health Maintenance Organization Assistance Act of 1973

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health reimbursement arrangement (HRA)

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health savings account (HSA)

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health savings security account (HSSA)

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independent practice association (IPA) HMO

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individual practice association (IPA) HMO

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legislation

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mandates

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network model HMO

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open-panel HMO

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physician incentive plan

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staff model HMO

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standards

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quality assessment and performance improvement (QAPI)

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Health Insurance – Ch 3 (Managed Health Care) – Flashcards

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