What does "appropriate services" mean? - pt is receiving the right care, at the right time and in the right HC setting.
How do you manage each pts care? - tailored to each individual's med needs by the CM or UR areas
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What does "appropriate services" mean? - pt is receiving the right care, at the right time and in the right HC setting.
How do you manage each pts care? - tailored to each individual's med needs by the CM or UR areas of managed care
Basic Concepts of Managed Care plans: - *Comp set of HC services for monthly premium
*Network of providers contracted for payment & delivery of care
*Providers required to meet quality and standards of care
*Practice guidelines to encourage a prop use of serv to improve outcomes & manage costs
*Quality assurance & UR program requirements
What is UR? - Utilization Review is the process of eval whether med, and Sx serv are appropriate, med nesses, & high quality.
Managed care nurses review ____________ _________, ______ ________ and _______ _______ using defined _____ _____ ______. - hospital admissions, surgical services, and ongoing treatment ; care mgmt. criteria
Prior to services rendered is called: - Preauthorization
After services rendered is called: - Retrospectively
While services are being rendered is called: - Concurrently
What does appropriate services for member mean? - the care utilized works in concert with a specific benefit plan
How is the use of network services beneficial? - helps control costs, and provides members with most efficient, safe, effective, and quality care available.
What are some of the most notable changes to occur since the initiation of The Affordable Care Act? - *The elimination of preexisting clause which prevents person from being deemed "insurable".
What is Managed Care? - method of healthcare
delivery designed to provide the highest quality of
care at the most cost effective means available.
Why was the managed care system developed? -
response to dramatic increases in healthcare costs
resulting from the explosion of new medical
technology and treatments
How are HC services provided under managed
care? - through a contracted methodology of
payment
What's the purpose of using a contracted
methodology of payment? - means of controlling
unnecessary costs through UM of med and
pharmacy serv and treatments through evalu
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