My Type
Patients can go to in and out of network HCP. May have to pay co-pays. If going out of network, it will cost you more.
What is Preferred Provider Organization (PPO)
Health care plans, health care clearinghouses and healthcare providers who engage in certain electronic transactions are know as these.
What is a covered entity?
MCO's are regulated from these three areas.
What is federal government, states and from voluntary accreditation?
These are individuals covered under a managed care plan.
Who are "enrollees"?
These are the 3 major functions MCO's typically perform.
What is 1. set up contracts and organizations of the healthcare providers who furnish healthcare to enrollees. 2. Establish the list of covered benefits tied to MC rules. 3. Oversee the healthcare they provide?
Patients must have a PCP but can go out of network. Typically don't have deductible if they go in network.
What is Point of Service? (POS)
HIPAA was enacted in this year.
What is 1996?
This organization is considered the "predominant standards-setting and accrediting body in healthcare in the US.
What is the Joint Commission?
This an organization established to provide a selection of structured and competitive options for purchasing health coverage.
What is the "healthcare marketplace"?
Although managed care dates back to the 19th century, it took until this time for managed care acceptance and respect among both physicians and the general public.
What is the 1970's?
Patients can only go in-network. If they select a provider outside of network without approval they will pay the entire bill. PCP determines the need for a specialist.
What is HMO?
What is:
1. Maintaining patient confidentiality. 2. Implementing standards for electronic transmission of transactions and code sets. 3. Establishing national provider and employer identifiers. 4. Resolving security and privacy issues arising from storage and transmission of health care data.
The standards of the Joint Commission outlines these items.
What is performance expectations for activities that affect the safety and quality of patient care.
This is also known as a PCP.
What is a "gatekeeper"?
Providers are paid a fixed rate, per capita amount for each individual enrolled in the plan regardless of how many or few services the patient uses.
What is "capitation"?
Patients can go to any physician, hospital or HCP. May have to pay an annual deductible and be responsible for co-insurance.
What is traditional insurance/indemnity plan?
When PHI is disclosed but can be helped it is called this.
What is an "incidental disclosure"?
This is the predominant accrediting body in managed care today.
What is National Committee for Quality Assurance? (NCQA)
This allows healthcare providers and patients to securely access and share a patient's vital medical information electronically.
What is Health Information Exchange (HIE)?
This is what a Medicare managed care plan is called.
What is "Medicare Advantage Plan".
This is also known as a consumer directed health plan. This plan includes high deductibles that the family is financially responsible for. Deductible is at least $1400.00 individual or $2800.00 family.
What is a High Deductible Plan??
If a provider is noncompliant with HIPAA standards, it could cost them how much?
What is $100 (for a general requirement violation) to $50,000 for more serious offenses such as wrongful disclosure of PHI.
These are what the NCQA look for in MCO's.
What is measures, assesses and reports on the quality of care and service in MCO's?
Method by which a patient is pre-approved for coverage of a specific healthcare service, procedure or prescription drug.
What is preauthorization or precertification?
Medical services, procedures or supplies that are reasonable and necessary for the diagnosis or treatment of a patient's medical condition is called this.
What is "medically necessary"?