1. Identify 8 managed care contracting terms:
a. Administrative services only (ASO): Usually associated with self-funded groups, this is when an insurance company, HMO, or third-party administrator provides claims-processing services, but the employer pays the claim costs. Administrative services usually include billing, enrollment, and coordination of benefits, payment check processing, subrogation, fraud investigation, and network rental.
b. Coordination of benefits (COB): Provision regulating payments when a person is covered by more than one healthcare policy. For example, if an employee is covered under a group plan and also under a spouse’s plan, the companies will ...view middle of the document...
HMOs have three distinct characteristics: 1) an organized system for providing health care in a specific geographic area, 2) a specific set of basic and supplemental health maintenance and treatment services and 3) a voluntarily enrolled group of people.
f. Integrated delivery system: A financial or contractual relationship between physicians and hospitals to offer a range of healthcare services through a separate legal entity. Models of these arrangements include physician-hospital organizations (PHOs), medical foundations, integrated provider organizations (IPOs), and management service organizations (MSOs).
g. Medical necessity: The evaluation of medical services to determine if they’re: 1) medically necessary and appropriate to meet basic health needs, 2) consistent with the diagnosis, 3) rendered in a cost-effective manner and 4) consistent with national medical practice guidelines.
h. Standard benefits package: A specific set of healthcare benefits that would be offered by an integrated delivery system. This could include preventive care, hospital and physician services, prescription drugs, long-term care, and mental health services.
Terms and definitions referenced from: Managed Care Resources, Inc.
Managed care is a system in which hospitals, physicians and other healthcare professionals are arranged in such a manner that the cost of the services is integrated with quality of the services. These are presented as attractive customized packages to the clients. The customer can choose the package that would be suitable to them as per their individual needs.
With the beginning of managed care back in the early 19th...