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Accreditation

voluntary process that a healthcare facility or organization undergoes to demonstrate that it has met standards beyond those required by law

Cafeteria Plan

also called triple option plan, provides different health benefits plans and extra coverage options through an insurer or third-party administrator

Capitation

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

Case Management

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

Customized sub-capitation plan (CSCP)

managed care plan in which healthcare 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 need from that provider

Enrollees

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

Exclusive provider organization (EPO)

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

Fee-for-service

reimbursement methodology that increase payment if the healthcare services fees increase, if multipe units of service are provided, or if more expensive services are provided instead of less expensive services (eg brand name vs generic prescrption medication)

Gag clause

prevents 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 nonessential care, and referring patients to specialist

Health Maintenance Organization (HMO)

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

Medical foundation

nonprofit organization that contracts with and acquires the clinical and business assests of physician practices, the foundationis assigned a provider number and manages the practice's business

Network provider

physician or healthcare facility under contract to the managed care plan

Physician incentives

includes payments made directly or indirectly to healthcare providers to serve as encouragement to reduce or limit services to save money for the managed care plan (eg discharge a patient from the hospital more quickly)

Physician-hospital organization (PHO)

owned by hospitals and physicians group that obtain managed care plan contracts, physician maintain their own practice and provided healthcare services to plan members

Point-of-serive plan (POS)

delivers healthcare services using both managed care network and traditional indemnity coverage so patiens can seek care outside the managed care network

Preferred provider orgainization (PPO)

network of physician and hospitals that have joined together to contract with insurance companies, employers, or other organization to provide health care to subscribers for a discount fee

Primary care provider (PCP)

responsible for supervising and coordination healthcare services for enrollees and preauthorizing referrals to specialist and inpatient hospital admissions

Risk pool

created when a number of people are grouped for insurance purposes, the cost of healthcare coverage is determined by employees' health status, age, sex, and occupation

Second surgical opinion (SSO)

second physician os asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery (eg. outpatient clinic or doctor's office versus inpatient hospitalization)

Triple option plan

usually offered by either a single insurance plan or as a joint venture among two or more third-party payers, and providers subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans also called cafeeria plan or flexible benifit plan

Utilzation Management (review)

method of controlling healthcare cost and quality of care by reviewing the appropreatenss and necessity of care provided to patients prior to the administration of care

Utilzation review organization (URO)

entity that establishes a utilzation management progarm and performs external utilization review services

Self-referral

enrollee who sees a non-HMO panel specialist without a referral from the primary care physician

Managed care

combines healthcare delivery with the financing of services provided ( managed health care)

integrated delivery system (IDS)

organization of affiliated providers sites that offer joint healthcare services to subscribers (eg. hospitals,ambulatory surgical centers, or physician groups)

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