Managed Health care Insurance Questions!

Preauthorization refers to the process of obtaining approval from a healthcare provider or insurance company before receiving a specific healthcare service. This is done to ensure that the service is medically necessary and will be covered by the insurance plan. In this context, preauthorization grants prior approval for reimbursement of a healthcare service, indicating that the service has been reviewed and deemed necessary by the insurance company before it is provided.

A POS (Point of Service) plan allows patients to choose whether to use providers within the managed care panel or to self-refer to non-managed care providers. This means that patients have the flexibility to go outside of the network and see specialists or providers of their choice without a referral, but they will have higher out-of-pocket costs compared to using in-network providers. This option gives patients more control over their healthcare decisions and allows them to access a wider range of providers if needed.

Enrollees is the best term to describe those who receive managed healthcare plan services. This term refers to individuals who have enrolled or signed up for a managed healthcare plan and are therefore eligible to receive the services provided by the plan. It specifically focuses on the individuals who are actively participating and utilizing the healthcare services offered by the plan, distinguishing them from other stakeholders such as employees, payers, and providers who may have different roles and responsibilities within the healthcare system.

Discharge planning refers to the process of arranging appropriate healthcare services for patients who are being discharged from a healthcare facility. This includes coordinating with various healthcare providers, such as home health agencies or rehabilitation centers, to ensure that the patient's needs are met after leaving the hospital. Discharge planning aims to ensure a smooth transition from hospital to home or another care setting, and it involves assessing the patient's needs, providing education and support to the patient and their family, and coordinating follow-up care.

HMO stands for Health Maintenance Organization. It is a type of healthcare plan that provides comprehensive healthcare services to voluntarily enrolled members on a prepaid basis. This means that members pay a fixed monthly fee, regardless of the amount of healthcare services they use. HMOs typically have a network of healthcare providers that members must use in order to receive coverage, and referrals from a primary care physician are often required to see specialists. HMOs focus on preventive care and often require members to choose a primary care physician who coordinates their healthcare.

Managed health care was implemented with the aim of replacing fee-for-service plans with affordable, quality care for healthcare consumers. This means that instead of the traditional system where healthcare providers are paid based on the number of services they provide, managed care organizations would focus on delivering cost-effective and high-quality care to patients. The goal was to improve the healthcare delivery system in the United States by making it more accessible and affordable for consumers.

A pre-admission review refers to the evaluation of the medical necessity for inpatient care before a patient is admitted to a healthcare facility. This process involves assessing the patient's condition, medical history, and treatment plan to determine if hospitalization is necessary. It helps ensure that the appropriate level of care is provided and helps manage healthcare costs by avoiding unnecessary admissions.

Concurrent review refers to the process of evaluating the medical necessity of tests and procedures ordered during a patient's inpatient hospitalization. This involves reviewing the ongoing care and treatment provided to ensure it aligns with the patient's medical needs and is appropriate for their condition. Concurrent review helps to ensure that the tests and procedures being performed are necessary and beneficial for the patient's overall health and recovery. It also helps in managing healthcare costs and ensuring that resources are being utilized efficiently.

The remaining $20,000 is retained by the medical center as profit. This means that after spending $80,000 to cover the healthcare services provided to the managed care enrollees, the medical center is left with $20,000. Instead of distributing this amount equally among the 150 enrollees, submitting it to the managed care organization, or turning it over to the federal government, the medical center keeps it as profit.

A primary care provider is responsible for supervising and coordinating healthcare services for enrollees. They serve as the main point of contact for patients and oversee their overall healthcare needs. This includes coordinating specialist referrals, managing chronic conditions, and providing preventive care. Primary care providers play a crucial role in ensuring that patients receive appropriate and timely healthcare services, making them the most suitable option for supervising and coordinating healthcare services for enrollees.

A non profit organization that contracts with and acquires the clinical and business assets of physician practices is called a medical foundation. Medical foundations are established to provide support and resources to physicians, allowing them to focus on patient care while the foundation handles administrative and financial aspects of their practice. This arrangement helps streamline operations and improve efficiency within the healthcare system.

Accreditation organizations are responsible for setting and maintaining specific standards for various industries or sectors. These standards outline the requirements and criteria that organizations must meet in order to achieve accreditation. Therefore, the term that describes requirements created by accreditation organizations is "standards."

A PPO (Preferred Provider Organization) is a contract network of healthcare providers that offer care to subscribers at a discounted fee. Unlike HMOs and EPOs, PPOs provide more flexibility to the subscribers in choosing their healthcare providers. Subscribers can receive care from both in-network and out-of-network providers, although the cost-sharing is typically higher for out-of-network services. This allows subscribers to have a wider range of options and access to specialists without needing a referral from a primary care physician.

EPO stands for Exclusive Provider Organization. It is a type of health insurance plan that provides benefits to subscribers who are required to receive services from network providers. This means that individuals covered under an EPO plan must seek medical care from healthcare providers within the designated network in order to receive coverage. Unlike other plans, EPOs do not require a referral from a primary care physician to see a specialist.

IDS stands for Integrated Delivery System. It is an organization of affiliated providers that offer joint healthcare services to subscribers. IDSs are designed to provide coordinated and comprehensive care to patients by integrating various healthcare services, such as hospitals, clinics, and physician practices, under one umbrella. This allows for better communication and collaboration among providers, leading to improved quality of care and better patient outcomes. IDSs often focus on population health management and work towards achieving cost-effective and efficient healthcare delivery.