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medicial billing and coding > chapter 3 managed health care > Flashcards

chapter 3 managed health care Flashcards

1
Q

ACCREDITATION

A

VOLUNTARY PROCESS THAT A HEALTH CARE FACILITY OR ORGANIZATION UNDERGOES TO DEMONSRTRATE THAT IT HAS MET STANDARDS BEYOND THOSE REQUIRED BY LAW

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2
Q

ADVERSE SELECTION

A

COVERING MEMBERS WHO ARE SICKER THAN THE GENERAL POPULATION

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3
Q

AMENDEMENT TO THE HMO ACT OF 1973

A

LEGISLATION THAT ALLOWED FEDERALLY QUALIFIED HMO’S TO PERMIT MEBERS TO OCCASIONALLY USE NOT HMO PHYSICIANS AND BE PARTIALLY REIMBURESED

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4
Q

CAFETERIA PLAN

A

PROVIDES DIFFERENT HEALTH BENFIT PLANS AND EXTRA COVERAGE OPTIONS THRUGH AN INSURER OR THIRD PARTH ADMINISRATOR

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5
Q

CAPITAATION

A

PROVIDER ACCEPTS PREESTABLISHED PAYMENTS FOR PROCIDING HEALTH CARE SERVICES TO ENROLLEES OVER A PERIOD OF TIME

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6
Q

CASE MANAGER

A

SUBMITS WRITTEN CONFIMATION AUTHORIZING TREATMENT TO THE PROVIDER

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7
Q

CLOSED PANEL HMO

A

HEALTH CARE IS PRIVIDED IN AN HMO OWNED CENTER OR SATELLITE CLINIC OR BY PROVIDERS WHO BELONG TO A SPECIALLY FORMED MEDICAL GROUP THAT SERVES THE HMO

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8
Q

COMPETITIVE MEDICAL PLAN

A

HMO THAT MEETS FEDERAL ELIGIBILITY REQUIREMENTS FOR A MEDICARE RISK CONTRACT BUT IS NOT LICENSED AS A FEDERALLY QUALIFIED PLAN

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9
Q

CONSUMER DIRECTED HEALTH PLAN

A

COSNSUMER DRIVEN HEALTH PLAN

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10
Q

CUSTOMIZED SUB CAPITATION PLAN

A

MANAGED CARE PLAN IN WHICH HEALTH CARE 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

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11
Q

DIRECT CONTRACT MODEL HMO

A

CONTRACTED HEALTH CARE SERVICES DELIVERED TO SUBSCRIBE BY INDIVIDUAL PROVIDERS IN THE COMMUNITY

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12
Q

ENROLLEES

A

ALSO CALLED COVERED LIVES EMPLOYEES AND DEPENDENTS WHO JOIN A MANAGED CARE PLAN

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13
Q

EXCLUSIVE PROVIDER ORGANIZATION EPO

A

MANAGED CARE PLAN THA TPROVIDES BENFITAS TO SUBSCRTIBES IF THEY RECEIVE SERVICES FORM NETWORK PROVIDERS

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14
Q

EXTERNAL QUALITY REVIEW ORGANIZATION

A

RESPONSIBLE FOR REVIEWING HEALTH CARE PROVIED BY MANAGED CARE ORGANIZATIONS

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15
Q

FEDERALLY QUALIFIED HMO

A

CERTIFIED TO PROVIDE HEALTH CARE SERVICES AND MEDICARE AND MEDICAID ENROLLEES

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16
Q

FEE FOR SERVICE

A

REIMBURSEMNET METHODOLOGY THAT INCREASES PAYMENT IF THE HEALTH CARE SERVICE FEES INCREASE

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17
Q

FLEXIBLE BENEFIT PLAN

A

CAFETERIA PLAN

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18
Q

FLEXIBLE SPENDING ACCOUNT FSA

A

TAX EXEMPT ACCOUNT OFFERED BY EMPLOYERS WITH ANY NUMBER OF EMPLOYEES WHICH INDIVIDUALS USE TO PAY HEALTH CARE BILLS

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19
Q

GAG CLAUSE

A

PERVENTS PROVIDERWS FORM DISCUSSING ALL TREATMENT OPTIONS WITH PATIENTS

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20
Q

GATEKEEPER

A

PRIMARY CARE PROVIDER FOR ESSENTIIAL HEALTH CARE SERVICES AT THE LOWEST POSSIBLE COST

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21
Q

GROUP MODLE HMO

A

CONTRACTED HEALT CARE SERVICES DELIVERED TO SUNSCRIBERS BY PARTICIPATING PROVIDERS

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22
Q

GROUP PRACTICE WITHOUT WALLS

A

CONTRACT THAT ALLOWS PROVIDERS TO MAINTAIN THEOIR OWN OFFICES AND SHARE SERVICES

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23
Q

HEALTH CARE RIMBURSEMENT ACCOUNT

A

USED TO PAY FOR HEALTH CARE EXPENNSES

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24
Q

HEALTH MAINTENANCE ORGANIZATION HMO

A

RESPONSIBLE FOR PROVIDINGN HEALTH CARE SEVICES SUBSCRTIBERS IN A GIVEN GEOGRAPHIVCAL AREA

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25
Q

HEALTH MAINTENCE ORGANIZATION ASSISTANCE ACT OF 1973

A

GRANTS AND LOANS TO DEVELOP HMOS A
ONE THA THAS APPKIED OFR AND MET FEDERAL STANDAREDS

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26
Q

HEALTH REIMBURSEMENT ARRANGEMENT

A

OFFERED BY EMPLOYERS WITH 50 OR MOREEMPLOYEES

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27
Q

HEALTH SAVINGS ACCOUNT

A

FLEXIBLE SPENDING ACCOUNT

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28
Q

HEALTH SAVINGS SECURITY ACCOUNT

A

FLEXIBLE SPENDING

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29
Q

HEALTHCARE EFFECTIVENESS DATA ADN INFORMATION SET

A

STANDARDS TO ASSESS MANGED CARE SYSTEMS USING DATE ELEMENTS THAT ARE COLLEDCTED

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30
Q

INDEPENDENT PRACTICE ASSOCIATION IPA HMO

A

INDIVIDUAL PRACTICE ASSOCIATION

31
Q

INDIVIDUAL PRACTICE ASSOCIATION

A

HMO WHERE CONTRACTED HEALTH SERVICES ARE DELIVERED TO SUBSCRIBES

32
Q

INTEGRATED DELIVERY SYSTEM

A

OFFER JOINT HEALTH CARE SERVICES TO SUBSCRIBERS

33
Q

INTEGRATEDE PROVIDER ORGANIZATION

A

MANAGTES THE DELIVERY OF HEALTH CARE SERVICES

34
Q

LEGISLATION

A

LAWS

35
Q

MANAGED CARE ORGANIZATION

A

RESPONSIBLE FOR HEALTH OF GROUP OF ENROLLEES

36
Q

MANAGED HEALTH CARE

A

COMBINES HEALTH CARE DELIVERY WITH THE FINACING OF SERVICES PROVIDED

37
Q

MANAGEMENT SERICE ORGANIZATION

A

OWNED BY PHYSICIANS OR HOSPITAL AND PROVIDES PRACTICE MANAGEMENT

38
Q

MANDATES

A

LAWS

39
Q

MEDICAL FOUNDATION

A

NONPROFIT ORGANIZATION THAT CONTRACTS WITH AND ACQUIRES THE CLINICAL AD BUSINESS ASSETS OF PHYSICIAN PRACTICES

40
Q

MEDICARE RISK PROGRAM

A

FEDERALLY QUALIFIED HMOS

41
Q

NATIONAL COMMITTEE FOR QUALITY ASSURANCE

A

PRICATE NOT FOR PROFIT ORGANIZATION THAT ASSESSES THE QUALITY OF MANGANED CARE PLANS

42
Q

NETWORK MODEL HMO

A

HEALTH CARE SEVICES PROVIDED TO SUBSCRIBERS BY 2 OR MOR PHYSICIANS

43
Q

NETWORK PROVIDER

A

OTHER HEALTH CARE PRACTITIONER OR HEALTH CARE FACILITY UNDER A MANAGED CARE PLAN

44
Q

OFFICE OF MANAGED CARE

A

CMS AGTIOENCY THAT FACILITATES INNOVATION AND COMPETITION AMONG MEDICARE HMOS

45
Q

OPEN PANNEL HMO

A

INDIVIDUALS WHO ARE NOT EMPLOYEES OF THE HMO OR WHO DO NOT BELONG TO A SPECIALLY FORMED MEDICAL GROUP

46
Q

PHYSICSIAN INCENTIVE PLAN

A

MANAGED CARE PLANS THAT CONTRACT WITH MEDICARE OR MEDICAID TO DISCLOSE INFORMATION ABOUT PHYSICIAN INCENTIVE PLANS

47
Q

PHYSICIAN INCENTIVES

A

PAYMENTS MADE DIRECTLY OR INDIRECTLY TO HEALTH CARE PROVDIERS

48
Q

PHYSICIAN HOSPITAL ORGANIZATION PHO

A

PHYSICIAN GROUPS THA TOBTAIN MANAGED CARE PLAN CONTRACTS

49
Q

POINT OF SERVICE PLAN POS

A

DELIVES HEALTH CARE SERVICES USING BOTH MANAGED CARE NETWORK AND TRAITIONAL

50
Q

PREFERRED POVIDER HEALTH CARE ACT OF 1985

A

EASED RESTRICTIONS ON PREFERRED PROVIDER ORGANIZZATIONS

51
Q

PREFERRED PROVIDR ORGANIZATION

A

OTHER HEALTH CARE PRACTITONERS AND HOSPITALS THAT HAVE JOINED THOGETHER TO CONTRACT WHITH INSURANCE COMPANIES

52
Q

PRIMARY CARE PROVIDER PCP

A

SUPERVISING AND COORDINATING HEALTH CARE SERVICES FOR ENROLLEES AND PREAUTHORIZING REFERRALS

53
Q

QUALITY ASSESSMETN AND PERFORMANCE IMPROVEMENT

A

QUALITY ASSURANCE ACTIVITES ARE PERFORMED TO IMPROVDE THE FUNCTIONING PF MEDICARE ADVANTAGE ORGANIZTIONS

54
Q

QUALITY ASSURANCE PROGRAM

A

ACTIVITES THAT ASSESS THE QUALITY OF CARE PROVIDED IN A HEALTH CARE SETTING

55
Q

QUALITY IMPROVEMENT SYSTEM FOR MANGED CARE

A

ENSURE ACCOUNTABILITY PF MANAGED CARE PLANS IN TERMS OF OBJECTIVE

56
Q

REPORT CARD

A

DATA REGARDING A MANAGED CARE PLANS QUALITY

57
Q

RISK ADJUSTMENT

A

PAYMENTS TO HEALTH PLANS ACCOUNTING FOR DIFFERENCES IN EXPECTED HEATLH COST OF ENROLLEES

58
Q

RISK ADJUSTMENT MODEL

A

PAYMENTS TO HEALTH PLANS THAT DISPOROPORTIONATELY ATTRACT HIGHER RISK ENROLLEES

59
Q

RISK ADJUSTMENT PROGRAM

A

LESSENS OR ELIMINATES THE INFLUENCE OF RISK SELECTION

60
Q

RISK CONTRACT

A

ARRANGENT AMONG PROVIDERS TO PROVIDE CAPITATIED HEALTH CARE SERVICES

61
Q

RISK POOL

A

NUMBER OF PEOPLE ARE GROUPED FOR INSURANCE PURPOSES

62
Q

RISK TRANSER FORMULA

A

TRANSFERS FUNDS FROM HEALTH PLANS WITH RELATIVELU LOWER RISK OR ENROLLEES

63
Q

SECOND DURGICAL OPINION

A

EVALUATE THE NECESSITY OF SURGERY

64
Q

SELF REFERRAL

A

NON HMO PANEL SPECIALIST WITHOUT AN REFERRAL

65
Q

STAFF MODEL HMO

A

PROVIDED TO SUBSCRIBES BY PHSICIANS AND OTHER HEALTH CARE PRACTITIONERS

66
Q

STANDARDS

A

REQUIREMENTS

67
Q

SUB CAPTATION PAYMENT

A

PROVIDER IS PAID A FIXED AMOUNT PRER MONTH

68
Q

SUBSCRIBERS

A

PERSONS WHOS NAME IS INSURANCE POLICY IS ISSUED

69
Q

SURVERY

A

ACCREDIATION ORGAI=NIZT=ATIO

70
Q

TRIPLE OPTION PLAN

A

SINGLE INSURANCE PLAN OR AS A JOIN VENTURE

71
Q

UTILIZATION REVIEW ORGANIZATION

A

UTILIZATION MANAGEMENT PROGRAM

72
Q

MEDICARE RISK PROGRAMS

A

HMOS AND COMPETITICE MEDICLA PLANS THAT MEET SPECIFIED MEDICARE REQUIREMENTS

73
Q

GAG CLAUSES

A

PREVENTS PROVIDES FROM DISCUSSING ALL TREATMENT OPTIONS WITH PATIENTS

74
Q

CONSUMER DIRECTED HEALTH PLANS

A

CONSUMER DRIVEN HEALTH PLAN

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