A healthcare delivery system that manages and coordinates medical services for its enrolled members, often through contracts with healthcare providers and facilities. MCOs typically focus on cost-effectiveness and quality of care.
A type of MCO that provides healthcare services through a network of providers for a fixed prepaid fee. Members usually must select a primary care physician and obtain referrals for specialists.
A type of MCO that contracts with a network of healthcare providers who agree to provide services at reduced rates to the MCO’s members. Members have more flexibility in choosing providers but may pay higher out-of-pocket costs for out-of-network services.
A hybrid of HMO and PPO, where members can choose to receive services within the network at lower costs or seek care outside the network with higher out-of-pocket expenses.
A payment model in which MCOs pay healthcare providers a fixed amount per enrollee per month regardless of the actual services provided. This incentivizes providers to deliver cost-effective care.
The process used by MCOs to assess the appropriateness, necessity, and efficiency of healthcare services provided to patients. It helps control costs by ensuring that only necessary services are rendered.
In an HMO, the primary care physician who manages and coordinates a patient’s healthcare services. Patients typically need a referral from their gatekeeper to see specialists or receive certain medical services.
A proactive approach to coordinating healthcare services for patients with complex medical needs. Case managers work with patients, providers, and insurers to ensure that appropriate care is delivered efficiently.
Continuous efforts by MCOs to monitor and improve the quality of healthcare services provided to their members. This may involve collecting and analyzing data, implementing best practices, and addressing areas for improvement.
An arrangement where MCOs and healthcare providers share financial responsibility for the cost of care. This can incentivize providers to deliver high-quality, cost-effective care while also mitigating financial risks for MCOs.