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27 terms

Chapt. 3 Insurance Test Review

STUDY
PLAY
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