Chpt 3

Front 1

QISMC

Back 1

Quality Improvement System for Manager Care

Front 2

QISMC was established by

Back 2

Medicare to ensure accountablility of managed care plans in terms of objective, measurable standards

Front 3

PCP

Back 3

Primary Care Physician provide care for enrollees on managed care plan

Front 4

JC

Back 4

Joint Commission performs healthcare accreditation

Front 5

Before scheduling an elective surgery, a______ may be required by the insurance company

Back 5

second surgical opinion (SSO)

Front 6

Captation

Back 6

pre-established payments for healthcare services

Front 7

CDHP

Back 7

Consumer-Directed Health Plan is not a managed care plan

Front 8

Case Management

Back 8

is development of patient care plans

Front 9

A plan offered either by a single insurance plan or joint venture by two or more insurance carriers and which provides subscribers or employees with a choice of HMO, PPO or traditional health plan can be called by the following names:

Back 9

· Flexible benefit plan

· Cafeteria plan

· Triple option plan

Front 10

Phsician Incentives

Back 10

encourage physicians/providers to reduce or limit services

Front 11

Consumer-Directed Health Plans (CDHP) provide

Back 11

incentives for controlling healthcare expenses and gives individuals an alternative to traditional health insurance and managed care coverage

Front 12

Medical Foundation

Back 12

is a nonprofit organization that contacts and acquires the clinical business assets of physician practices

Front 13

Risk pool

Back 13

a number of people are grouped for insurance purposes and cost of health coverage is determined by employees' health status, age, sex, and occupation

Front 14

Point of Service Plan (POS)

Back 14

patients may use HMO providers or self refer to non-HMO providers

Front 15

Customized Sub-Capitation Plan (CSCP)

Back 15

a type of consumer-directed health plan (CDHP) where the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium

Front 16

MSO

Back 16

provides practice management services to individuals physician practices

Front 17

The "Report Card" contains data regarding managed care plan's:

Back 17

· Quality

· Utilization

· Financial stability

Front 18

Enrollees

Back 18

are employees and dependents who joins a managed care plan

Front 19

PCP

Back 19

"GATEKEEPER"

Front 20

Gag Clause

Back 20

prevents providers from discussing all treatment options with patients

Front 21

Network Provider

Back 21

Physician or healthcare provider under contract to a managed care plan

Front 22

Managed healthcare was designed to

Back 22

replace traditional fee-for-service plans with more afforable quality healthcare to patients.

Front 23

PPO

Back 23

Preffered Provier Organization

Front 24

PPO

Back 24

a network of physicians and hospitals that have joined together to contract with insurance companies, employers and other organization to provide healthcare to subscribers for a discounted fee.

Front 25

HMO is a health maintenance organization. It is an alternative to traditional group health insurance coverage and provides:

Back 25

· Comprehensive healthcare services to

· Voluntarily enrolled members

· On a prepaid basis

Front 26

In a managed care plan, enrollees receive care from a_______ who is doctor that serves as a "gatekeeper" by provding essential health care services at the lowest possible cost

Back 26

PCP

Front 27

The Joint Commission (JC) discontinued its Network Accreditation Program for Managed Care Organizations in

Back 27

January 2006

Front 28

HMO

Back 28

provide preventative care services to promote wellness

Front 29

Physician-Hospital Organization

Back 29

is owned by hospital(s) and physician groups and obtain managed care contracts

Front 30

The National Committee for Quality Assurance

Back 30

is non-profit organization that assesses the quality of managed care plans in the U.S.

Front 31

Fee-for-Service

Back 31

reimburses providers fro individual healthcare services provided

Front 32

Utilization Management/Review

Back 32

is a method of controlling healthcare costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to administration of care

Front 33

Examples of managed care plans are:

Back 33

· Triple Option Plan (TOP)

· Point of Service (POS)

· Exclusive Provider Organization (EPO)

Front 34

Accreditation

Back 34

voluntary process that a healthcare facility or organization undergoes to demonstrate it has met standards beyond those required by law

Front 35

Managed Care Organization

Back 35

is responsible for the health of a group of enrollees and can be a health plan, hospital, physician group or health system

Front 36

Case Management

Back 36

the development of patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner

Front 37

SSO

Back 37

Second Surgicial Opinion: the second physician is asked to evaluate the necessity of surgery and recommend the most economic, appropriate facility