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10 terms

Ch. 3 Managed Health Care

STUDY
PLAY
Utilization Management (utilization review)
A method of controlling healthcare costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care (prosp, method of controlling healthcare costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care (prospective review) or after care had been provided (retrospective review).
Subscribers (policyholders)
AKA enrolees....employees and dependents who join a managed care plan.
Sub-capitation payment
Each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider.
Self-referral
A patient in a managed care plan (HMO) that refers himself or herself to a specialist.
Primary Care Provider (PCP)
A general practice, or nonspecialist provider or physician responsible for the care of a patient, preauthorizing referrals and inpatient hospital admissions. (Not ER admissions)
Preferred Provider Organization (PPO)
Managed care network of health care providers who agree to perform services for plan members at discounted fees.
Point-of-Service Plan (POS)
A health plan that allowsyou to choose providers inside or outside the plan, but at a higher premium if choose outside plan.
Network Provider
Physician or healthcare facility under contract to the managed care plan.
Medicare + Choice
Expands on the Medicare coverage options by creating managed care plans, to include HMO's, PPO's, and MSA's (now called Medicare Advantage or Medicare Part C)
Integrated Provider Organization
Manages the delivery od healthcare services offered by hospitals, physicians employed by the IPO, and othe rhealthcare organizations.