Exam 7: Unraveling the Mysteries of Managed Care

An independent nonprofit organization that measures,assesses,and reports on the quality of care and service in MCOs.

Members of an HMO normally pay only a relatively small fee (called a copayment)each time they visit their healthcare provider.

A multispecialty practice in which healthcare services are provided within the building complex owned by the health maintenance organization (HMO)is referred to as a/an:

An advantage of managed care organizations (MCOs)is that their aim is to keep their enrollees healthy,which is commonly referred to as:

A "hybrid" type of managed care (also called an open-ended HMO)that allows patients either to use their HMO provider or to go outside the plan and use a provider of their choices is a/an ____________________.

The formal term for a written complaint submitted by an individual covered by a special plan or policy is called a:

Under the federal HMO act,an entity must have five characteristics to call itself an HMO.

When a patient is sent to another provider (often a specialist)with the intent of rendering an expert opinion only,this is a/an ____________________.(Hint: Total care is not transferred.)

A process used by health insurance companies to control healthcare costs,similar to preauthorization,is ____________________.

The two most common types of managed care organizations are ___________ and ____________.

A referral is exactly the same as a consultation.

A/an __________,similar to the group model HMO,allows multiple provider arrangements,but services are provided at multiple sites by multiple groups so that a wider geographic area is served.

A common process used by many healthcare payers to monitor and control healthcare costs by prior evaluation and necessity of most hospitalizations and certain medical services.

Explain how the Affordable Care Act relates to managed care.

A request by a healthcare provider for his or her patient to be evaluated or treated by a specialist is a:

The predominant accrediting body in managed care that measures,assesses,and reports on the quality of care and service in MCOs is _____________.

The new healthcare reform bill promotes __________.

A complex healthcare system in which hospitals and healthcare professionals organize an interrelated system of people and facilities that works together as a unit describes:

Precertification is a process people must go through to become eligible to join an HMO.

Healthcare reform will likely eliminate most managed care arrangements.