1
Q
accreditation
A
voluntary process that a health care facility or organization (e.g., hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law.
2
Q
adverse selection
A
covering members who are sicker than the general population.
3
Q
Amendment to the HMO Act of 1973
A
legislation that allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be partially reimbursed.
4
Q
cafeteria plan
A
also called triple option plan; provides different health benefit plans and extra coverage options through an insurer or third-party administrator.
5
Q
capitation
A
provider accepts preestablished payments for providing health care services to enrollees over a period of time (usually one year).
6
Q
case manager
A
submits written confirmation, authorizing treatment, to the provider.
7
Q
closed-panel HMO
A
health care is provided in an HMO-owned center or satellite clinic or by providers who belong to a specially formed medical group that serves the HMO.
8
Q
consumer-directed health plan (CDHP)
A
see consumer-driven health plan.
9
Q
customized sub-capitation plan (CSCP)
A
managed care plan in which health care expenses are funded by insurance coverage; the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium; each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider (called a sub-capitation payment).
10
Q
direct contract model HMO
A
contracted health care services delivered to subscribers by individual providers in the community.
11
Q
enrollees
A
also called covered lives; employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans.
12
Q
exclusive provider organization (EPO)
A
managed care plan that provides benefits to subscribers if they receive services from network providers.
13
Q
external quality review organization (EQRO)
A
responsible for reviewing health care provided by managed care organizations.
14
Q
federally qualified HMO
A
certified to provide health care services to Medicare and Medicaid enrollees.
15
Q
fee-for-service
A
reimbursem*nt methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services (e.g., brand name vs. generic prescription medication).
16
Q
flexible benefit plan
A
see cafeteria plan and triple option plan.
17
Q
flexible spending account (FSA)
A
tax-exempt account offered by employers with any number of employees, which individuals use to pay health care bills; participants enroll in a relatively inexpensive, high-deductible insurance plan, and a tax-deductible savings account is opened to cover current and future medical expenses; money deposited (and earnings) is tax-deferred, and money is withdrawn to cover qualified medical expenses tax-free; money can be withdrawn for purposes other than health care expenses after payment of income tax plus a 15 percent penalty; unused balances “roll over” from year to year, and if an employee changes jobs, the FSA can continue to be used to pay for qualified health care expenses; also called health savings account (HSA) or health savings security account (HSSA).
18
Q
gag clause
A
prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursem*nt for services.
19
Q
gatekeeper
A
primary care provider for essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists.
20
Q
group model HMO
A
contracted health care services delivered to subscribers by participating providers who are members of an independent multispecialty group practice.
21
Q
group practice without walls (GPWW)
A
contract that allows providers to maintain their own offices and share services (e.g., appointment scheduling and billing).
22
Q
health care reimbursem*nt account (HCRA)
A
tax-exempt account used to pay for health care expenses; individual decides, in advance, how much money to deposit in an HCRA (and unused funds are lost).
23
Q
legislation
A
laws.
24
Q
health maintenance organization (HMO)
A
authorized grants and loans to develop HMOs under private sponsorship; defined a federally qualified HMO as one that has applied for, and met, federal standards established in the HMO Act of 1973; required most employers with more than 25 employees to offer HMO coverage if local plans were available.
25
Q
Health Maintenance Organization (HMO) Assistance Act of 1973
A
authorized grants and loans to develop HMOs under private sponsorship; defined a federally qualified HMO as one that has applied for, and met, federal standards established in the HMO Act of 1973; required most employers with more than 25 employees to offer HMO coverage if local plans were available.
26
Q
health reimbursem*nt arrangement (HRA)
A
tax-exempt accounts offered by employers with 50 or more employees; individuals use HRAs to pay health care bills; HRAs must be used for qualified health care expenses, require enrollment in a high-deductible insurance policy, and can accumulate unspent money for future years; if an employee changes jobs, the HRA can continue to be used to pay for qualified health care expenses.
27
Q
health savings account (HSA)
A
see flexible spending account.
28
Q
health savings security account (HSSA)
A
see flexible spending account.
29
Q
Healthcare Effectiveness Data and Information Set (HEDIS)
A
created standards to assess managed-care systems using data elements that are collected, evaluated, and published to compare the performance of managed health care plans.
30
Q
individual practice association (IPA) HMO
A
see individual practice association (IPA) HMO.
31
Q
integrated delivery system (IDS)
A
manages the delivery of health care services offered by hospitals, physicians employed by the IPO, and other health care organizations (e.g., an ambulatory surgery clinic and a nursing facility).
32
Q
integrated provider organization (IPO)
A
manages the delivery of health care services offered by hospitals, physicians employed by the IPO, and other health care organizations (e.g., an ambulatory surgery clinic and a nursing facility).
33
Q
managed care organization (MCO)
A
responsible for the health of a group of enrollees; can be a health plan, hospital, physician group, or health system.
34
Q
managed health care (managed care)
A
combines health care delivery with the financing of services provided.
35
Q
management service organization (MSO)
A
usually owned by physicians or a hospital and provides practice management (administrative and support) services to individual physician practices.
36
Q
Mandates
A
laws.
37
Q
medical foundation
A
nonprofit organization that contracts with and acquires the clinical and business assets of physician practices; the foundation is assigned a provider number and manages the practice’s business.
38
Q
medical foundation
A
nonprofit organization that contracts with and acquires the clinical and business assets of physician practices; the foundation is assigned a provider number and manages the practice’s business.
39
Q
Medicare risk program
A
federally qualified HMOs and competitive medical plans (CMPs) that meet specified Medicare requirements provide Medicare-covered services under a risk contract.
National Committee for Quality Assurance (NCQA)
40
Q
network model HMO
A
contracted health care services provided to subscribers by two or more physician multispecialty group practices.
41
Q
network provider
A
physician, other health care practitioner, or health care facility under contract to the managed care plan.
42
Q
Office of Managed Care
A
CMS agency that facilitates innovation and competition among Medicare HMOs.
43
Q
open-panel HMO
A
health care provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO.
44
Q
physician incentive plan
A
developed the International Classification of Diseases (ICD).
45
Q
physician incentives
A
include payments made directly or indirectly to health care providers to serve as encouragement to reduce or limit services (e.g., discharge an inpatient from the hospital more quickly) to save money for the managed care plan.
46
Q
physician-hospital organization (PHO)
A
owned by hospital(s) and physician groups that obtain managed care plan contracts; physicians maintain their own practices and provide health care services to plan members.
47
Q
point-of-service plan (POS)
A
delivers health care services using both managed care network and traditional indemnity coverage so patients can seek care outside the managed care network.
48
Q
Preferred Provider Health Care Act of 1985
A
eased restrictions on preferred provider organizations (PPOs) and allowed subscribers to seek health care from providers outside of the PPO.
49
Q
preferred provider organization (PPO)
A
network of physicians, other health care practitioners, and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee.
50
Q
primary care provider (PCP)
A
responsible for supervising and coordinating health care services for enrollees and preauthorizing referrals to specialists and inpatient hospital admissions (except in emergencies).
51
Q
quality assessment and performance improvement (QAPI)
A
program implemented so that quality assurance activities are performed to improve the functioning of Medicare Advantage organizations.
quality assurance program
52
Q
Quality Improvement System for Managed Care (QISMC)
A
activities that assess the quality of care provided in a health care setting.
53
Q
report card
A
contains data regarding a managed care plan’s quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control.
54
Q
Risk adjustment
A
method of adjusting capitation payments to health plans, accounting for differences in expected health costs of enrollees.
55
Q
risk contract
A
method of adjusting capitation payments to health plans, accounting for differences in expected health costs of enrollees.
56
Q
risk pool
A
created when a number of people are grouped for insurance purposes (e.g., employees of an organization); the cost of health care coverage is determined by employees’ health status, age, sex, and occupation.
57
Q
second surgical opinion (SSO)
A
second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery (e.g., outpatient clinic or doctor’s office versus inpatient hospitalization
58
Q
self-referral
A
enrollee who sees a non-HMO panel specialist without a referral from the primary care physician.
59
Q
staff model HMO
A
enrollee who sees a non-HMO panel specialist without a referral from the primary care physician.
60
Q
standards
A
requirements.
61
Q
sub-capitation payment
A
each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider.
62
Q
subscribers (policyholders)
A
person in whose name the insurance policy is issued.
63
Q
survey
A
conducted by accreditation organizations (e.g., The Joint Commission) and/or regulatory agencies (e.g., CMS) to evaluate a facility’s compliance with standards and/or regulations.
64
Q
triple option plan
A
usually offered by either a single insurance plan or as a joint venture among two or more third-party payers, and provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans; also called cafeteria plan or flexible benefit plan.
65
Q
utilization review organization (URO)
A
entity that establishes a utilization management program and performs external utilization review services.
