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26 terms

chapter 3

STUDY
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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)