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The health care plan that reimburses providers for individual health care services provided is a

fee-for service plan

What organization is responsible for the health of a group of enrollees and can be health plan, hospital, physician group, or health system?

Managed Care Organization

Managed care plan enrollees receive care from?

their primary care provider

A method of controlling health care costs and quality of care by reviewing the appropriateness and necesity of care provided to patients prior to the administration of care is

utilization management

Prior to scheduling elective surgery, managed care plans often require

second surgical opinion

What organization is owned by hospital(s) and physician groups that obtain managed care plan contracts

physician-hosptial organization

A network of physicians and hosptials that have joined together to contract with insurance companies to provide healthcare to subscribers for a discounted fee is a

preferred provider organization

A plan offered either by a single insurance plan or as a joint venture by two or more insurance carriers, and which provides subscribers or employees with a choice of HMO, PPO, or traditional health plan, is a

Triple option, cafetaria, or flexible plan

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

risk pool

________is 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

accreditation

When the individual selects onf of each type of provider to create a customized network and pays the resulting customized insurance premium; what type of consumer-directed health plan would this be

customized sub-capitation plan (CSCP)

Consumer-directed health plans provide incentives for controlling health care expenses and give individuals a_________ to traditional health insurance and managed care coverage

choice

Which of the following is not an example of a managed care plan

integrated delivery system

Federal legislation mandated that Managed Care Organizations (MCO's) participate in quality assurance programs and other activities including

utilization and case managements, requirements for second surgical opinions, dislcosure of any physician incentive.

Triple option plan

Subscriber or employee may choose between HMO,PPO, or traditional health insurance plan

Enrollees

employees and dependents who join a managed care plan

Capitation

Pre-established payments for health care services

Case management

development of patient care plans

Physician incentives

encouragement to reduce or limit services

Network provider

physician or health care provider under contract to manage care plan

HMO

provides health care to enrolled members on prepaid basis

PPO

physican and hosptials joined together to contract with insurance companies for a discounted fee

Medical foundation

Non-profit organization that contracts with and acquires the clinical and business assets of physician practices

Point of service plan

patients may use HMO providers or self-refer to non-HMO providers

Risk pool

people grouped for insurance purposes, cost determined by employees health status, age, sex, and occupation

Joint Commission

health care accreditation

MSO

provides practice management services to individual physician practices

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