Unit 17 Health and Life - HMO/PPOS

HMO (Health Maintenance Organization)

Managed care plan with prepaid services, co-pays, a gatekeeper PCP, limited provider choice, and limited service area

Gatekeeper

A primary care physician who must approve referrals to specialists in an HMO

Preferred Provider Organization (PPO)

Managed care plan using fee-for-service with pre-negotiated rates; insured pays less using in-network providers

Point of Service (POS)

An "open-ended HMO" allowing subscribers to use out-of-network providers without a gatekeeper, but at higher cost

Preventive Care (Cost Containment)

A managed care strategy to reduce future healthcare costs

Second Surgical Opinion

A cost containment measure requiring a second opinion before surgery

Preauthorization (Precertification)

Requires approval before certain treatments or procedures to control costs

Limits on Length of Stay

A cost containment measure restricting how long a patient can stay hospitalized

Alternatives to Hospital Care

Skilled nursing facilities, intermediate nursing facilities, rehabilitative facilities, and home health care

Prospective Review

Utilization management review conducted before treatment

Concurrent Review

Utilization management review conducted during treatment

Retrospective Review

Utilization management review conducted after treatment