Chapter 3 Managed Health Care

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Accrediation

voluntary process that a healthcare facility or organizaiton (e.g., hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law.

Adverse Selection

covering members who are sicker than the general population.

Cafeteria Plan

also called triple option plan; provides different health benefit plans and extra coverage options through an insurer or third-party admindstrator.

Capitation

provider accepts preestablished payments for providing a healthcare services to enrollees over a period of time (usually one year).

Case Management

Development of patient care plans to coordinate and provide care for complicated cases in a cost-effective mannner.

Case Manager

submits written confirmation, authorizing treatment, to the provider.

Closed-Panel HMO

health care is provided in an HMO-owned center or satelitie clinic or by physicians who belong to a specially formed medical group that serves the HMO.

Concurrent Review

which is a review for medical necessity of tests and procedures ordered during an inpatient hosplization.

Consumer-Directed Health Plan (CDHP)

which define employer contributions and ask employees to be more responsible for healthcare decisions and cost-sharing.

Direct Contract Model HMO

contracted healthcare services delivered to subscribers by individual physicians in the comunity.

Discharge Planning

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

Enrollees

Employees or Individuals who are covered under a managed care plan.

Exclusive Provider Organization (EPO)

Managed care plan that provides benefits to subscribers if they receive services from network providers.

Federally Qualified HMO

Certified to provide healthcare services to Medicare and Medicaid enrollees.

Fee-for-Service

reimbursement methodology that increases payment if the healthcare service fees increase, if multiple units of service are provided or if more expsensive services are provided instead of less expensive services. (e.g., brand-name vs. generic prescription medication)

Flexible Benefit Plan

see cafeteria plan or triple option plan

Flexible Spending Account (FSA)

tax-exempt account offered by employers with any number of employees, which individual use to pay healthcare bills; participants enroll in a relatively inexpensive, high-deductible insurance plan, and a tax-deductible saving account is opened to cover current and future medical expenses; money deposited (and earninso is tax-deferred, and money is withdrawn to cover qualified medical expenses tax-free; money can be withdrawn for purposed other than healthcare expenses after payment of income tax plus a 15 percent penalty; unsued balances "roll over" from year to year, and if an employee changed jobs, the FSA can continue to be used to pay for qualified healthcare expneses; also called health saving account (hsa) or health savings security account (hssa).

Gag Clause

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

Gatekeeper

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

Group Model HMO

contracted healthcare services delivered to subscribers by participating physicians who are members of an independent mutispecialty group practice.

Health Maintenace Organization (HMO)

responsible for providing healthcare services to subscribers in a given geographical area for a fixed fee.

Individual Practice Association (IPA) HMO

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

Integrated Delivery Systems

Organizations of affiliated provider sites (e.g., hospitals, ambulatory surgical centers, or physician groups) that offer joint healthcare services to subscribers.

Integrated Provider Organization (IPO)

manages the delivery or healthcare services offered by hospitals, physicians employed by the IPO, and other healthcare organizations (e.g., an ambulatory surgery clinic and a nursing facility).

Legislation

the act of making or enacting laws

Managed Care Organization (MCO)

responsible for the health of a group of enrollees; can be a health plan, hospital, physician group, or health systems.

Mandates

laws

Medical Foundation

is a 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.

Medical Savings Account (MSA)

tax-exempt trust or custodial account established for the purpose of paying medical expenses in conjuction with a high-deductible health plan; allows individuals to withdraw tax-free funds for healthcare expenses, which are not covered by a qualifiying high-deductible health plan.

Medicare+Choice

also called Medicare Advantage (Medicare Part C); includes managed care plans and private free-for-service plans, whihc provide care under contract to Medicare and may include such benefits as coordination of care, reductions in out-of-pocket expenses, and prescription drugs. Medicare enrollees have the option of enrolling in one of several plans.

Medicare Risk Program

federally qualified HMOs and competive medical plans (CMPs) that meet specified Medicare requirements provide Medicare covered services under a risk contract.

Network Model HMO

contracted healthcare services provided to subscribers by two or more physician multispecialty group practices.

Network Provider

Physician or healthcare facility under contract to the managed care plan.

Open-Panel HMO

health care provided by individuals who are not employees of the HMO or who do not belong to a specialty-formed medical group that serves the HMO.

Physician Incentive Plan

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.

Physician Incentives

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

Point-of-Service Plan (POS)

delivers healthcare services using both managed care network and traditional indemity coverage so patients can seek care outside the managed care network.

Preadmission Certification (PAC)

or preadmission review, which is a review for medical necessity of inpatient care prior to the patient's admission.

Primary Care Provider (PCP)

responsbile for supervising and coordinating healthcare services for enrollees and preauthorizing referrals to specialists an inpatient hospital admissions (exempt in emergenices).

Report Card

contains data regarding a managed care plan's quality, utilizatin, customer satisfaction, admininstrative effectiveness, financial stability, and cost control.

Self-Referral

enrollee wo sees a non-HMO panel specialist w/o a referral from the primary care provider.

Staff Model HMO

Healthcare services are provided to subscribers by physicians employed by the HMO.

Standards

levels of quality, skill, or ability considered to be normal

Sub-Capitation Payment

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

Utilization Management (utilization review)

method of controlling healthcare costs and quality of care by reviewing the appropriateness and ncessity of care provided to patients prior to the administration of care.

Utilization Review Organization (URO)

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

What does PCP serves as?

Gatekeeper

What have some managed care organizations done?

they have discontnued capitation and have adopted fee-for-service payment plans.

What have managed care programs successful done.

they have been containing costs and limiting unnecessary services, resulting in the current trend for healthcare plans to offer the SSO as a benefit, not a requirement.

Second Surgical Opinion (SSO)

that is, a 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).

What have governement and private payers been implemented?

they implemented managed care programs to control healthcare costs.

What do EPO patients receive?

they receive care from participating providers, or they pay for all costs incurred.

What is the IDS result of?

of a joint venture between hospitals and members of their medical staff.

What is required by managed care plans?

coinsurance is required of managed care plans when out-of-network (nonparticipating) providers rneder healthcare services to plan subscribers.

What do HMO often require?

they require a copayment (or copay), which is a fee paid by the patient to the provider at the time healthcare services are rendered.

What does POS requiring patient to do?

they are requiring patients to pay a higher-copayments and deductibles when allowing patients to obtain health services from out-of-network providers.

What does PPO include?

groups of healthcare providers that provide discounted fee-for-service services to patients.

What can HMO manage?

patient healthcare services by expending a monthly capitation amount paid by a third-party payer.

Triple Option Plan

which is usually offered either by a single insurance plan or as a joint venture among two or more insurance payers, provides subscribers or employees wiht a choice of HMO, PPO, or traditional health insurance plans.

What does a TPO provide?

patients with more choices than a traditional managed care plan.

What will the Joint Commission do?

on January 1, 2006; it will discontinued its network Accrediation Program for Managed Care Organizations.

Is it important to realize that managed care is an option.

yes, that many payers use to reimburse healthcare.

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