other health plans

What is a health maintenance organization

Hmos are managed Care entities that provide both healthcare service and healthcare financing

Since an HMO is a financing entity it assumes

The cost of medical care will not exceed the subscription fees

What is a capitation fee

A fixed monthly fee that the HMO company pays to a healthcare provider based on the number of HMO members they have not visits or services

What is the gatekeeper concept of an HMO

To control over utilization, subscribers must have a gatekeeper or primary care physician who they must always see first accept in emergencies when seeking medical Care. This is who issues referrals to specialists.

Hmos seek to reduce the need for medical treatment by detecting conditions early. This means that they have an emphasis on

Preventative care

What types of services are offered by hmos that are included in the subscription fee

Preventative services like routine physicals immunizations, diagnostic screening

If an HMO subscriber receives emergency care outside of the limited service area or limited service network the HMO must

Reimburse the subscriber

What is a preferred provider organization

A PPO is a managed care entity on a fee for service basis where prices are pre-negotiated and insureds pay less in network but are still covered for a percentage out of network

What type of plan is closed panel

Hmo

What type of plan is open panel

Hmo

What is a point of service plan

A POS plan is a type of HMO that like a PPO allows subscribers to visit out of network physicians

A gatekeeper PPO or open-ended HMO are both

Point of service plans

An indemnity plan also called a traditional insurance plan are characterized by

Fee for service, complete freedom of choice of provider, specialists without a referral

What is healthcare cost? Containment or managed care

The measures used by insurance companies to control healthcare costs

What are some services used in managed Care

Preventative care and reducing hospital care costs

For cost containment, how are hospital care costs reduced

Outpatient benefits, second surgical opinions, pre-authorization pre-certification, limits on length of stay, alternatives to hospital care

As an alternative to hospital care skilled nursing facilities offer

Round the clock care for patients who do not require the acute level of care provided by a hospital

As an alternative to hospital care intermediate nursing facilities provide

Intermittent nursing care for patients who do not need 24-hour supervision

As an alternative to hospital care rehabilitative facilities provide

Limited medical Care along with personal care for patients. Recovering from major surgeries or serious injuries or illness

As an alternative to hospital care, home health care provides

Ongoing medical Care for people who do not need supervision

For utilization management perspective review means

A review of the case before expensive tests or treatment also called pre-certification or pre-authorization

Under utilization management concurrent review means

A second opinion or a review that takes place while treatment is being provided

Under utilization management retrospective review means

A review done after treatment is complete to evaluate if it was effective and if anything could be changed to produce better or more cost-effective outcomes in future