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Introduction to Managed Health Care
Healthcare Delivery System
Medical Management 1
Medical Management 2
Special Markets
100
This piece of Federal legislation was a major boot to the HMO movement.
What is 1973 federal HMO Act?
100
This physician acts as a gatekeeper, authorizing referrals to specialists when necessary.
What is a primary care physician?
100
The reduction of practice variation by establishing parameters for cost-effective use of health care resources.
What is utilization management?
100
The underlying business of health insurance and health plans is the management of risk, which is actuarially driven. This service provides the ability to execute the business.
What is Information Technology?
100
This MCO offers a range of primary, secondary, and tertiary care benefits to approximately 9.2 million eligible beneficiaries.
What is TRICARE?
200
This insurance simply provides insurance against financial loss.
What is indemnity insurance?
200
MCO do this to ensure a level of quality and acceptability among their physicians and to protect themselves from potential liability should a dispute arise regarding a certain provider.
What is Credentialing?
200
The premise behind this MCO activity is that chronic conditions, although representing a relatively small number of plan members, represent the majority of costs.
What is Disease Management?
200
The 3 driving factors in Health care reform.
What are Access, Quality and Cost?
200
This healthcare program was originally developed for low-income people.
What is Medicaid?
300
These organizations typically create a provider network for covered individuals by contracting directly with hospitals, physicians, and diagnostic facilities.
What are Preferred Provider Organizations (PPOs)?
300
A system of prepayment for services on a per-member, per month basis (PMPM).
What is capitation?
300
This is the process of evaluating a patient in a fully integrated way and addressing the full spectrum of services required to meet the patient's needs during the acute phase of illness as well as at discharge.
What is Case Management?
300
This is the process of automatically determining eligibility and correctly applying benefits and payment terms for each claim using predetermined rules without any human intervention.
What is auto-adjudication?
300
This federal entitlement program has been in place since 1965.
What is Medicare?
400
These organizations are organized healthcare systems that are responsible for financing and delivering a range of comprehensive health services.
What are Health Maintenance Organizations (HMOs)?
400
The fundamental goal of this compensation plan is to align financial rewards with improvements in the use of evidence-based medical practice and safety in order to promote better outcomes as efficiently as possible.
What is P4P?
400
This benefit is offered in more than 92% of managed care plans. The goal of this benefit is to address the supply cost and the utilization demand of this expense.
What is Prescription Drug Benefits?
400
The 4 major players in health care reform and improvement.
What is the patient, provider, employer, and insurance company?
400
This benefit is provided by private plans, either prescription drug plans (PDP) or Medicare Advantage Prescription Drug (MA-PD) plans.
What is Medicare D?
500
These plans combine a high-deductible health insurance policy with some form of pretax fund. Consumers are responsible for any costs not covered by insurance or these accounts. Such plans strive to make information on cost and quality available to consumers to help them make decisions.
What are Consumer-directed health plans (CDHPs)?
500
Health plans are now posting the fees that they will pay providers for common types of services and providers, as well as estimated costs if a member goes out of network. This is intended to enable consumers to make informed choices.
What is price transparency?
500
These services covered by MCOs may take place in inpatient services, residential treatment, partial hospitalization, intensive outpatient treatment, regular outpatient treatment and Employee Assistance Programs.
What are types of behavioral health services?
500
The Institute of Medicine's Committee on the Quality of Health Care in America proposed six aims for health care system improvements in its report Crossing the Quality Chasm (2001). These aims are ______, ______, Patient Centered, Timely, Efficient and ______. Fill in the blanks.
What is Safe, Effective, Equitable
500
This combined medicare and private health plan will be phased out gradually by the Affordable Care Act.
What is Medicare Advantage (MA)?