Create an account
voluntary process that a healthcare facility or organization undergoes to demonstrate that it has met standards beyond those required by law
also called triple option plan, provides different health benefits plans and extra coverage options through an insurer or third-party administrator
provider accepts preestablished payments for providing healthcare services to enrollees over period of time (usually a year)
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
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
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)
prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services
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
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
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
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
enrollee who sees a non-HMO panel specialist without a referral from the primary care physician
combines healthcare delivery with the financing of services provided ( managed health care)
Please allow access to your computer’s microphone to use Voice Recording.
Having trouble? Click here for help.
We can’t access your microphone!
Click the icon above to update your browser permissions and try again
Reload the page to try again!Reload
Press Cmd-0 to reset your zoom
Press Ctrl-0 to reset your zoom
It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.
Please upgrade Flash or install Chrome
to use Voice Recording.
For more help, see our troubleshooting page.
Your microphone is muted
For help fixing this issue, see this FAQ.
Star this term
You can study starred terms together