Managed care is an all inclusive system that brings together both delivery and payment. This system utilizes management techniques that gear towards promoting the delivery of healthcare in a way that is most cost effective. The contract between two entities such as a doctor or other health care related businesses is an important resource that defines the relationship. Any type of provision within the contract may directly affect organizations outcomes through payment, procedures, and even clinical decision making. Below are eight different managed care contracting terms and their definition.
Competitive Medical Plan, also known as CMP, is given to certain organizations that meet certain requirements. This status grants the organizations that meet those specific requirements the ability to obtain a Medicare risk or cost based contract.
Lock in is a contractual provision in which members may receive their care only from health providers in network. The only exception is in cases where emergency or urgent care is needed.
TEFRA, or Tax Equity and Fiscal Responsibility Act of 1982 is a managed care contract term. TEFRA is the Federal law that is responsible for the creation of the current risk and cost contract provision.
Preferred Providers is a term used to identify physicians, clinics, or other health care providers that are associated with a particular health plan.
Prepaid Health Plan, also known as PHP operates on a prepaid basis. The services this plan provides are those that are not risk comprehensive. They contract on a non risk basis. There are some entities that are treated as PHP’s only if they meet the criteria above.
PPO, or Preferred Provider Organization, is a type of system that negotiates with medical care providers. PPO systems negotiate rates with medical care providers for services given to members of this particular plan. Members are allowed to seek medical care with providers that are not on the PPO plan, however, the member will ultimately be financially responsible for the bill.
Network Model HMO is a model which forms relationships with more than one group of physicians. This system may contract with either single or multi specialty groups. These groups normally work out of their own office.
Managed Health Care plan incorporates financing and management with the delivery of health care services to a certain group of people. It contacts with an organized system of providers that deliver services and often times shares financial risk.
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