Health Care Management

Running head : MANAGED CARE CONTRACTING TERMS

Eight Managed Care Contracting Terms

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Eight Managed Care Contracting Terms

Beneficiary Liability - The sum which the Medicare providers should receive from beneficiaries as payment for their rendered services Inclusive in these accountabilities are the following : copayments coinsurance amounts , and balance billing amounts ADDIN EN .CITE Pohly20071 1112Pam Pohly2007October 242007http /www .pohly .com /terms_d .html (Pohly , 2007

Ambulatory Care - Synonymous to outpatient care , provision of medical services

without admitting the patient to a hospital . Examples of these medical services are diagnosis , treatment , surgery , and rehabilitation in areas such as homes , physician 's offices , and ambulatory care centers ADDIN EN .CITE Institute22212Tufts Health Care Institute2007 October 24http /www .thci .org /o ther_resources /glossarymc .html hmo (Institute

Malpractice Insurance- This protects a patient against risks of financial damages by reason of professional misconduct or deficiency of ordinary skill . Proof of harm or damage due to professional negligence makes the medical practitioner liable to the malpractice ADDIN EN .CITE Pohly20071 1112Pam Pohly2007October 242007http /www .pohly .com /terms_d .html (Pohly , 2007

Non-Participating Physician / Provider - Any medical service provider either a doctor or a hospital , that do not have a contract which is included in the health plan . Medicare or any health plan is not obligated to pay for the medical services that is acquired by a beneficiary from a non- participating provider ADDIN EN .CITE Pohly20071 1112Pam Pohly2007October 242007http /www .pohly .com /terms_d .html (Pohly , 2007

Ethics in Patient Referrals Act - Stark Laws is the other name of this federal act which prohibits referral of patients to institutions such as laboratories , radiology services , pharmacies , and medical equipment suppliers by doctors that have financial interests or commissions in association with the said transaction ADDIN EN .CITE Pohly20071 1112Pam Pohly2007October 242007http /www .pohly .com /terms_d .html (Pohly , 2007

Point-of-Service Health Plan (POS ) - Also Known as the Open-ended Health Maintenance Organization (HMO , which is a combination of HMO features and indemnity insurance option . Members of this plan have an option to receive medical services from the HMO coverage or from providers without contract with the HMO . The members have the choice to avail the services already covered by the HMO or pay additional charges from out side providers

Utilization Management (UM ) - A systematic evaluation of the necessity appropriateness and efficiency of health services identification and implementation of the most excellent practices to attain cost effective but high quality health care and minimizing costs by removal of unnecessary treatments . This is used by health insurance companies managed care organizations , delivery systems , hospitals , and medical practitioners ADDIN EN .CITE Pohly20071 1112Pam Pohly2007October 242007http /www .pohly .com /terms_d .html (Pohly , 2007

Outcomes Measurement - System of systematic follow-up of clinical treatment and outcome of that treatment applied . Variation in the methodology used for the quantification of the outcomes exists between health service providers ADDIN EN .CITE Pohly20071 1112Pam Pohly2007October 242007http /www .pohly .com /terms_d .html (Pohly , 2007 .References

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