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31 Cards in this Set
- Front
- Back
gag clauses |
prevent providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services
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Second surgical opinion
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another physician is asked to evaluate the necessity of surgery and recommend the most economical appropriate facility in which to perform the surgery.
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Preadmission review
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review for medical necessity of inpatient care prior to the patient's admission
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point-of-service
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patients have freedom to use the managed care panel of providers or to self-refer to out-of-network providers.
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Risk pool
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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?
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eased
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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.
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federal, federally qualified plan
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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
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enrollees
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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
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employees
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Physician associated with an IPO are this
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ERISA
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Act of legislation that permits large employers to self-insure employee health care benefits
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Make a profit
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If a physician provides services that cost less than the managed care capitation amount, the physician makes this
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Supervision and coordination of health care services
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The primary care provider is responsible for this
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utilization management
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A method of controlling health care costs and quality of care by reviewing the appropriatness and necessity of care provided to patients
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voluntary
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Accreditation is this kind of process
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Customized sub-capitation plan
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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
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health care reimbursement account
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type of consumer-directed health plan carries the stipulation that any funds unused will be lost
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managed care plans
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Assessed by the National Committee for Quality Assurance
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Developing patient care plans
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A case manager is responsible for this
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million
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This is how many American are enrolled in some type of managed care program;
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Standards
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Accreditation organizations develop these to be reviewed during the survey process that is conducted both onsite and offsite
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HEDIS
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Was created to provide standards to assess managed care systems in terms of indicators such as membership, utilization of services, quality, and access
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OBRA
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Act of legislation provided states with the flexibility to establish HMOs for Medicare and Medicaid programs
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results of patient satisfaction surveys
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This would be the subject of a managed care plan quality review
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Medicare
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Quality Improvement System for Managed Care (QISMC) was established by this
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Discharge Planning
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Arranging for a patient's transfer to a rehabilitation facility is an example of this
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Third-party administrator
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Administrative services performed on the behalf of a self-insured managed care company can be outsourced to this
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Integrated delivery system (IDS)
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A health delivery network is another name for this
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Laws
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Mandate are this
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managed care
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Combines healthcare delivery with financing of services provided
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Medicare Modernization Act (MMA) |
A 2003 Legislation that allows tax deductions for amounts contributed to a health saving account
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Utilization Review Organization |
The plan can be contract with a TPA or this |