A Nurses Introduction to Managed Care
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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 [Show More]
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Jun 25, 2023
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