Health Insurance – Ch 3 (Managed Health Care) – Flashcards
79 test answers
Unlock all answers in this set
Unlock answers 79question
Risk contract
answer
An arrangement among providers to provide capitated (fixed, prepaid basis) health care services to Medicare beneficiaries.
Unlock the answer
question
Competitive Medical Plan (CMP)
answer
An HMO that meets federal eligibility requirements for a Medicare risk contract but is not licenses as a federally qualified plan.
Unlock the answer
question
Medical Savings Account (MSA)
answer
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)
Unlock the answer
question
Medicare+Choice
answer
Expanded Medicare coverage options by creating managed care plans, to include HMOs, PPOs, and MSAs.
Unlock the answer
question
Managed Care Organization (MCO)
answer
Is responsible for the health of a group of enrollees and can be a health plan,hospital, physician group, or health system.
Unlock the answer
question
Fee-for-service Plan
answer
This reimburses providers for individual health care services rendered.
Unlock the answer
question
Capitation
answer
Providers accept preestablished payments for providing health care services to enrollees over a period of time (usually one year).
Unlock the answer
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).
Unlock the answer
question
Quality Assurance Program
answer
Includes activities that assess the quality of care provided in a health care setting.
Unlock the answer
question
Report Card
answer
Contains data regarding a managed care plan's quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control.
Unlock the answer
question
Utilization Management
answer
(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.
Unlock the answer
question
Prospective Review
answer
Prior to the administration of care.
Unlock the answer
question
Retrospective Review
answer
After care has been provided.
Unlock the answer
question
Preadmission Certification (PAC)
answer
(Preadmission Review) A review for medical necessity of inpatient care prior to the patient's admission.
Unlock the answer
question
Preauthorization
answer
A review that grants prior approval for reimbursement of a health care service (e.g., elective surgery)
Unlock the answer
question
Concurrent review
answer
A review for medical necessity of tests and procedures ordered during an inpatient hospitalization.
Unlock the answer
question
Discharge planning
answer
Involves arranging appropriate health care services for the discharged patient (e.g., home health care)
Unlock the answer
question
Utilization Review Organization (URO)
answer
An entity that establishes a utilization management program and performs external utilization review services.
Unlock the answer
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. Case manager submits written confirmation, authorizing treatment, to the provider.
Unlock the answer
question
Second Surgical Opinion (SSO)
answer
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.
Unlock the answer
question
Gag clauses
answer
These prevent providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.
Unlock the answer
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.
Unlock the answer
question
Federal 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.
Unlock the answer
question
Exclusive Provider Organization (EPO)
answer
A managed care plan that provides benefits to subscribers who are required to receive services from network providers.
Unlock the answer
question
Network provider
answer
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.
Unlock the answer
question
Integrted 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.
Unlock the answer
question
Physician-hospital Organization (PHO)
answer
(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.
Unlock the answer
question
Management Service Organization (MSO)
answer
(IDS) Usually owned by physicians or a hospital and provides practice management (administrative and support) services to individual physician practices.
Unlock the answer
question
Group practice without walls (GPWW)
answer
(IDS) Estabslishes a contract that allows physicians to maintain their own offices and share services (e.g., appointment scheduling and billing)
Unlock the answer
question
Integrated provider organization (IPO)
answer
(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)
Unlock the answer
question
Medical foundation
answer
(IDS) A nonprofit organization that contracts with and acquires the clinical and business assets of physician practices.
Unlock the answer
question
Health Maintenance Organization (HMO)
answer
An alternative to traditional group health insurance coverage and provides comprehensive health care services to voluntarily enrolled members on a prepaid basis.
Unlock the answer
question
Point-of-service plan (POS)
answer
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.
Unlock the answer
question
Self-referral
answer
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.
Unlock the answer
question
Preferred Provider Organization (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.
Unlock the answer
question
Triple Option Plan
answer
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).
Unlock the answer
question
Risk Pool
answer
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.
Unlock the answer
question
Sub-capitation payment
answer
Each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider.
Unlock the answer
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.
Unlock the answer
question
Survey
answer
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).
Unlock the answer
question
National Committee for Quality Assurance (NCQA)
answer
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.
Unlock the answer
question
Preferred Provider Health Care Act of 1985
answer
Eased restrictions on preferred provider organizaitons (PPOs) - Allowed subscribers to seek health care from providers outside of the PPO
Unlock the answer
question
Amendment of the HMO Act of 1973
answer
Allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be partially reimbursed
Unlock the answer
question
Healthcare Effectiveness Data and Information Set (HEDIS)
answer
Created sstandards to assess managed-care systems in terms of membership, utilization of services, quality, access, health plan management and activities, and financial indicators
Unlock the answer
question
HCFA's Office of Managed Care
answer
Facilitated innovation and competitio among Medicare HMOs
Unlock the answer
question
External Quality Review Organizations (EQRO)
answer
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.
Unlock the answer
question
Quality Improvement System for Managed Care (QISMC)
answer
Established by Medicare to ensure the accountability of managed care plans in terms of objective, measurable standards (requirements)
Unlock the answer
question
Health Plan Employer Data and Information Set (HEDIS)
answer
Performance measures used to evaluate managed care plans. Sponsered by the National Committee for Quality Assurance (NCQA)
Unlock the answer
question
National Committee for Quality Assurance (NCQA)
answer
Reviews managed care plans and develops report cards to allow healthcare consumers to make informed decisions when selecting a plan.
Unlock the answer
question
Third-Party Administrator (TPA)
answer
An organization that provides health benefits claims administration and other outsourced services for self-insured companies.
Unlock the answer
question
adverse selection
answer
...
Unlock the answer
question
cafeteria plan
answer
...
Unlock the answer
question
closed-panel HMO
answer
...
Unlock the answer
question
customized sub-capitation plan (CSCP)
answer
...
Unlock the answer
question
direct contact model HMO
answer
...
Unlock the answer
question
federally qualified HMO
answer
...
Unlock the answer
question
flexible benefit plan
answer
...
Unlock the answer
question
flexible spending account (FSA)
answer
...
Unlock the answer
question
gatekeeper
answer
...
Unlock the answer
question
group model HMO
answer
...
Unlock the answer
question
healthcare reimbursement account (HCRA)
answer
...
Unlock the answer
question
Health Maintenance Organization Assistance Act of 1973
answer
...
Unlock the answer
question
health reimbursement arrangement (HRA)
answer
...
Unlock the answer
question
health savings account (HSA)
answer
...
Unlock the answer
question
health savings security account (HSSA)
answer
...
Unlock the answer
question
independent practice association (IPA) HMO
answer
...
Unlock the answer
question
individual practice association (IPA) HMO
answer
...
Unlock the answer
question
legislation
answer
...
Unlock the answer
question
mandates
answer
...
Unlock the answer
question
network model HMO
answer
...
Unlock the answer
question
open-panel HMO
answer
...
Unlock the answer
question
physician incentive plan
answer
...
Unlock the answer
question
staff model HMO
answer
...
Unlock the answer
question
standards
answer
...
Unlock the answer
question
quality assessment and performance improvement (QAPI)
answer
...
Unlock the answer
