CCMA - healthcare payment & ancillary service

managed care

an umbrella term for plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals

capitation (partial or full)

patients are assigned a per-member , per-month  payment based on age, race, sex, lifestyle, medical history, and benefit design. Payment rates are tied to expected usage regardless of how often the patient visits. Like bundled payment models, providers are incentivized to help patients avoid high-cost procedures and tests to maximize their compensation. Under partial- or blended-capitation models, only specific types or categories of services are paid based on capitation

health maintenance organization (HMO)

this plan contracts with a medical center or group of providers to provide preventive and acute care for the insured person. _____ generally require referrals to specialists, as well as precertification and preauthorization for hospital admissions, outpatient procedures, and treatments

preferred provider organization (PPO)

these plans have more flexibility than HMO plans. An insured person does not need a PCP and can go directly to a specialist without referrals. Although patients can see providers in or out of their network, an in-network provider usually costs less

point-of-service (POS) plan

____ plans allow a great deal of flexibility for patients. They can self-refer to specialists and do not need an assigned PCP. Like PPO, the cost depends on whether the providers they see are within the plan's panel

general practitioners (GP)

medical doctors who treat acute and chronic illnesses and provide patients with preventive care and heatlh education

family practitioners

offer care to the whole family , from newborns to older adults. They are familiar with a range of disorders and diseases. However, preventive care is their primary concern

internist

provide comprehensive care for adults, often diagnosing and treating chronic, long-term conditions. They also offer treatment for common illnesses and preventive care. _____ must have a broad understanding of the body and its ailments to diagnose conditions and provide treatment. ____ may focus on pediatric or adult medicine rather than provide care across the lifespan.

specialized care

is used when a disease or diagnosis escalates beyond the area of expertise of a PCP

allergist

Evaluates disorders and diseases of the immune system, including adverse reactions to medications and food, anaphylaxis, problems related to autoimmune disease, and asthma

anesthesiologist

manages pain or administers sedation medications during surgical procedures

cardiologist

diagnoses and treats diseases or conditions of the heart and blood vessels

dermatologist

diagnose and treat skin conditions

endocrinologist

diagnoses and treats hormonal and glandular conditions; often works with patients who have diabetes 

gastroenterologist

manages diseases of the GI tract (stomach, intestines, esophagus, liver, pancreas, colon, and rectum)

gynocologist

diagnoses and treats internal reproductive system and fertility disorders

hematologist

diagnoses and treats blood and blood-producing organs, patients who have anemia, leukemia, and lymphoma

Hepatologists

studies and treats diseases related to the liver , biliary tree, gallbladder, and pancreas

neonatologist

provides care of newborns , specifically those who are ill

nephrologist

manages diseases and disorders of the kidney and its associated structures

Obstetrician

provides care of patients during and after pregnancy 

oncologist

treats and provides care for patients who have cancer 

ophthalmologist

diagnoses and treats diseases and conditions of the eye 

orthopedist

treats injuries and diseases of the bones , joints, muscles, tendons, and ligaments

neurologist

treats diseases and disorders of the brain and nervous system

otolaryngologist

treats diseases and conditions of the ear , nose, and throat

pediatrician

manages newborn to adolescent health

psychiatrist

diagnoses and treats mental disorders and conditions

radiologist

uses and interprets imaging to detect abnormalities in the body

urologist

manages disorders of the urinary tract

urgent care

provides an alternative to the emergency department. They cost less, have a shorter wait time, and are often conveniently located. Most have flexible hours and offer walk-in appointments. They are appropriate to use for life threatening acute injuries and illnesses

laboratory services

perform diagnostic testing on blood , body fluids , and other specimans to conclude a diagnosis for the provider

diagnostic imaging

machines such as x-ray  equipment, ultrasound machines, magnetic resonance imaging (MRI), and computerized tomography (CT) take images of body parts to further diagnose a condition

occupational therapy

 assists patients who have conditions that disable them developmentally, emotionally, mentally, or physically.__________ helps the patient compensate for the loss of functions and rebuild to a functional level.

physical therapy

 assists patients in regaining mobility and improving strength and range of motion, often impaired by an accident, injury, or disease