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Flashcards in Final Study Deck Deck (66)
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Levels of Service

Based on the patient's condition and the needed level of care, used to identify and verify that the patient is receiving care at the appropriate level.


Quality Monitoring

A process used to ensure that care is being delivered at or above acceptable
quality standards and as identified by the organization or national guidelines.


Effectiveness of Care

The extent to which care is provided correctly (i.e., to meet the patient's needs, improve quality of care, and resolve the patient's problems), given the current state of
knowledge, and the desired outcome is achieved.


Quality Indicator

A predetermined measure for assessing quality; a metric.



The process of determining specific objectives, goals, and actions designed to meet the client’s needs as identified through the assessment process. The plan should be action-oriented and time-specific.


Quality Improvement

An array of techniques and methods used for the collection and analysis of data gathered in the course of current healthcare practices in a defined care setting to identify and
resolve problems in the system and improve the processes and outcomes of care.


Clinical Pathway
Case Management Plan (CMP)
Multidisciplinary Action PLan (MAP)

A timeline of patient care activities and expected outcomes of care that
address the plan of care of each discipline involved in the care of a particular patient. It is usually developed prospectively by an interdisciplinary healthcare team in relation to a patient's diagnosis, health problem, or surgical procedure.


Intensity of Service

An acuity of illness criteria based on the evaluation/treatment plan, interventions, and anticipated outcomes.



The ongoing process of gathering sufficient information from all relevant sources about
the case management plan and its activities and/or services to enable the case manager to determine the plan’s effectiveness.


First-Level Reviews

Conducted while the patient is in the hospital, care is reviewed for its appropriateness.


Managed Competition

A state of healthcare delivery in which a large number of consumers choose among health plans that offer similar benefits. In theory, competition would be based on cost and
quality and ideally would limit high prices and improve quality of care.



A measure or metric that can be used to monitor and assess quality and outcomes of
important aspects of care or services. It measures the performance of functions, processes, and outcomes of an organization.


Outcomes Measurement

The systematic, quantitative observation, at a point in time, of outcome indicators.


Efficiency of Care

The extent to which care is provided to meet the desired effects/outcomes to improve quality of care and prevent the use of unnecessary resources.


Outcome Indicators

Measures of quality and cost of care. Metrics used to examine and evaluate the results of the care delivered.


Partial Disability

The result of an illness or injury which prevents an insured from performing one or
more of the functions of his/her regular job.


Level of Care

he intensity of effort required to diagnose, treat, preserve or maintain an individual's
physical or emotional status.



The course of action adopted to care for a patient or to prevent disease.


Quality Assurance

The use of activities and programs to ensure the quality of patient care. These
activities and programs are designed to monitor, prevent, and correct quality deficiencies and noncompliance with the standards of care and practice.


Management Service Organization

A management entity owned by a hospital, physician organization, or third party. It contracts with payers and hospitals/physicians to provide certain
healthcare management services such as negotiating fee schedules and handling administrative functions, including utilization management, billing, and collections.


Quality Management

A formal and planned, systematic, organizationwide (or networkwide)
approach to the monitoring, analysis, and improvement of organization performance, thereby continually improving the extent to which providers conform to defined standards, the quality of patient care and services provided, and the likelihood of achieving desired patient outcomes.


Outcomes Management

The use of information and knowledge gained from outcomes monitoring to achieve optimal patient outcomes through improved clinical decision making and service delivery.


Continuous Quality Improvement (CQI)

A key component of total quality management that uses rigorous, systematic, organization-wide processes to achieve ongoing improvement in the quality of healthcare services and operations. It focuses on both outcomes and processes of care.


Severity of Illness

An acuity of illness criteria that identifies the presence of significant/debilitating
symptoms, deviations from the patient's normal values, or unstable/abnormal vital signs or laboratory findings.



The frequency with which a benefit is used during a 1-year period, usually expressed in
occurrences per 1000 covered lives.


Managed Care

A system of healthcare delivery that aims to provide a generalized structure and
focus when managing the use, access, cost, quality, and effectiveness of healthcare services. Links the patient to provider services.


Loss Expense Allocated

That part of expense paid by an insurance company in settling a particular claim, such as legal fees, by excluding the payments to the claimant.


Assignment of Benefits

Paying medical benefits directly to a provider of care rather than to a
member. This system generally requires either a contractual agreement between the health plan and
provider or written permission from the subscriber for the provider to bill the health plan.


Experience Refund

A provision in most group policies for the return of premium to the policyholder
because of lower than anticipated claims.


Target Utilization Rates

Specific goals regarding the use of medical services, usually included in
risk-sharing arrangements between managed care organizations and healthcare providers.