A term applied to a variety of direct contractual relationships between hospitals, physicians, insurers, employers, or third-party administrators for a network in which providers negotiate with group purchasers to provide health services for a defined population at a negotiated rate. The preferred providers are often subject to other stipulations regarding the monitoring of utilization and quality of care. Utilization management review Utilization review and intervention actions are a series of control techniques or processes used to identify and reduce inappropriate and unnecessary care services. A system for assessing, planning treatment for, referring, and monitoring patients to ensure the provision of comprehensive and continuous service and the coordination of payment and reimbursement for care. The actual prepayment to a provider or insurer for a negotiated package of comprehensive and continuous health care services.
Providers assume a greater portion of financial and service risk in most capitated systems.
A group of hospital systems, medical groups, and HMOs or insurance companies that form for the purpose of coordinating the continuum of care, eliminating redundant services, and developing comprehensive medical information systems under a single management system. These systems are willing to be held clinically and fiscally accountable for the outcomes and health status of the populations served. The goal is the delivery of health care in a seamless system. An integrated delivery system that provides its patients with access to all services needed for health care in a highly integrated manner, allowing the patient to move to different sites and services in the system with strong continuity of care.