Insurance Chapter 3

Front 1

gag clauses

Back 1

prevent providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services

Front 2

Second surgical opinion

Back 2

another physician is asked to evaluate the necessity of surgery and recommend the most economical appropriate facility in which to perform the surgery.

Front 3

Preadmission review

Back 3

review for medical necessity of inpatient care prior to the patient's admission

Front 4

point-of-service

Back 4

patients have freedom to use the managed care panel of providers or to self-refer to out-of-network providers.

Front 5

Risk pool

Back 5

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?

Front 6

eased

Back 6

The Preferred Provider Health Care Act of 1985 did this on preferred provider organizations (PPO's) and allowed subscribers to seek health care from providers outside of the PPO.

Front 7

federal, federally qualified plan

Back 7

A competitive medical plan (CMP) is an HMO that meets this kind of requirement requirements for a Medicare risk contract but is not licensed as this kind of plan

Front 8

enrollees

Back 8

A managed care organization (MCO) was developed as a way to provide affordable, comprehensive, prepaid health care services and are responsible for this group of people. Also called subscribers

Front 9

employees

Back 9

Physician associated with an IPO are this

Front 10

ERISA

Back 10

Act of legislation that permits large employers to self-insure employee health care benefits

Front 11

Make a profit

Back 11

If a physician provides services that cost less than the managed care capitation amount, the physician makes this

Front 12

Supervision and coordination of health care services

Back 12

The primary care provider is responsible for this

Front 13

utilization management

Back 13

A method of controlling health care costs and quality of care by reviewing the appropriatness and necessity of care provided to patients

Front 14

voluntary

Back 14

Accreditation is this kind of process

Front 15

Customized sub-capitation plan

Back 15

A type of health care funds health care expenses by insurance coverage and allows the individual to select one of each type of provider to create a customized network

Front 16

health care reimbursement account

Back 16

type of consumer-directed health plan carries the stipulation that any funds unused will be lost

Front 17

managed care plans

Back 17

Assessed by the National Committee for Quality Assurance

Front 18

Developing patient care plans

Back 18

A case manager is responsible for this

Front 19

million

Back 19

This is how many American are enrolled in some type of managed care program;

Front 20

Standards

Back 20

Accreditation organizations develop these to be reviewed during the survey process that is conducted both onsite and offsite

Front 21

HEDIS

Back 21

Was created to provide standards to assess managed care systems in terms of indicators such as membership, utilization of services, quality, and access

Front 22

OBRA

Back 22

Act of legislation provided states with the flexibility to establish HMOs for Medicare and Medicaid programs

Front 23

results of patient satisfaction surveys

Back 23

This would be the subject of a managed care plan quality review

Front 24

Medicare

Back 24

Quality Improvement System for Managed Care (QISMC) was established by this

Front 25

Discharge Planning

Back 25

Arranging for a patient's transfer to a rehabilitation facility is an example of this

Front 26

Third-party administrator

Back 26

Administrative services performed on the behalf of a self-insured managed care company can be outsourced to this

Front 27

Integrated delivery system (IDS)

Back 27

A health delivery network is another name for this

Front 28

Laws

Back 28

Mandate are this

Front 29

managed care

Back 29

Combines healthcare delivery with financing of services provided

Front 30

Medicare Modernization Act (MMA)

Back 30

A 2003 Legislation that allows tax deductions for amounts contributed to a health saving account

Front 31

Utilization Review Organization

Back 31

The plan can be contract with a TPA or this