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36 Cards in this Set
- Front
- Back
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Patient Protections and Affordable Care Act (PPACA) |
Dual purpose was to increase by approximately 30 million people, the number of Americans covered by health insurance, while decreasing the cost of insurance |
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PPACA |
Purpose was to transform the U.S. health insurance and make it more affordable through shred responsibility, and to eliminate discriminatory acts |
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Managed care |
The process of structuring or restructuring the healthcare system in terms of financing, purchasing, delivering, measuring, and documenting a broad range of healthcare services and products |
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Manage Care Organizations (MCOs) |
Represent a major shift away from the domination of the fee-for-service system toward networks of providers supplying a full range of services |
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Health Maintenance Organizations (HMOs) |
Organized healthcare systems that are responsible for both the financing and the delivery of a broad range of comprehensive health services to an enrolled population |
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Preferred Provider Organizations (PPOs) |
Entities through which employer health benefit plans and health insurance carriers contract to purchase healthcare services for covered beneficiaries form a selected group of participating providers |
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Exclusive Providers Organizations (EPOs) |
Limit their beneficiaries to participating providers for any healthcare services; use a gatekeeper approach to authorize non primary care services |
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Point-Of-Service (POS) Plans |
Use primary care physicians as gatekeepers to coordinate and control medical care |
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Experienced-Rated Benefit Options |
An HMO receives monthly premium payments |
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Specialty HMOs |
Provide limited components of healthcare coverage |
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Independent Practice Association (IPA) |
A legal entity composed of physicians organized for the purpose of negotiating contracts to provide physician services |
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Physician Group Practice |
Has only one or a small number of service delivery locations; completely integrated economically, sharing costs and revenues |
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Group Practice Without Walls |
A physician organization formed for the purpose of sharing some administrative and management costs while physicians continue to practice at their own locations rather than at a centralized location |
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Physician-Hospital Organization (PHO) |
A legal entity consisting of a joint venture of physicians and a hospital |
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Medical Foundation |
Employs or contracts with physicians to provide care to the foundation's patients |
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Management Service Organization (MSO) |
An entity that provides administrative and management services to physicians |
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Vertically Integrated Delivery System (IDS) |
Any organization or group affiliated organizations that provides physician and hospital services to patients |
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Horizontal Merger |
Involves similar or identical businesses at the same level of the market |
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HMOs |
Most highly regulate form of MCOs |
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Federally Qualified HMOs |
Must provide or arrange for basic health services for they members as needed and without limitation as to time, cost, frequency, extent, or kind of services actually provided |
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Case Management Firms |
Assist employers and insurers in managing catastrophic cases |
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Third-Party Administrator (TPA) |
A firm that provides services for employers and associations that have group insurance policies; acts as a liaison between the employer and the insurer |
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Utilization Review (UR) |
A process whereby a third-party payer evaluates the medical necessity of a course of treatment |
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Prospective Review |
Payer determines whether to pay for treatment before the treatment is initiated |
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Concurrent Review |
Review is performed during the course of treatment |
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Retrospective Review |
Review is performed after treatment has been completed |
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Utilization Management Firms |
Perform utilization management activities for managed care entities, insurers, or employers; mental health and dental care are two common types |
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Ostensible or Apparent Agency Theory |
MCOs may be able for the medical malpractice of non employee participating physicians if the patient reasonably views the entity (hospital) rather than the individual physician as the source of care and the entity engages in conduce that leads the patient t o believe that the course or care is the entity or that the physician is an employee of the entity |
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Doctrine of Corporate Negligence |
Clearly applies to staff-model HMOs in which the HMO employs the physician and provides the facility within which they offer care |
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Employee Retirement Income Security act of 1974 (ERISA) |
Designed to ensure that employee welfare and benefit plans conform to a uniform body of benefits law |
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ERISA |
Sets minimum standards for most voluntarily established pension and health plans in private industry to provide protections for individuals in these plans |
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Consolidated Omnibus Budget Reconciliation Act (COBRA) |
Included an amendment that expanded benefits, providing some workers and their families with the right to continue their health coverage for a limited time under certain circumstances |
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Health Care Quality Improvement Act of 1986 (HCQIA) |
Enacted in part as a response to numerous antitrust suits against participants in peer-reveiew and credentialing activities; encourages continuous participation in these actives |
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Market Power |
Results from the ability to cut back the market's total supply and then raise prices because of consumer demands for the product |
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Product Market |
Involved the product or service at issue and all substantially acceptable substitutes for it |
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Geographic Market |
The market area in which the seller operates and to which the purchaser can practically turn for supplies |
