Health Insurance Today ch 7

26 terms by KellieB

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Assessment

Network

An organized, interrelated system of people and facilities yhat communicate with one another work together as a unit is commonly referred to as a:

Enrollees

Individuals belonging to a managed healthcare plan are referred to as:

HMO's and PPO's

The most common types of MCO's are:

Primary care physicians (PCP)

A specific provider who oversees and HMO member's total healthcare treatment is called a:

PCP

When an individual first enrolls in a HMO, he/she chooses a:

Copayment

The amount of money a patient has to pay out-of-pocket per visit is referred to as a:

Preventive Healthcare

Most managed healthcare plans emphasize:

Staff Model

A multispecialty group practice where all healthcare services are provided within the building(s) owned by the HMO is called a:

Group Model

An HMO that contracts with independent, multispecialty physician groups that provide all healthcare services to its members and usually share the same facility, support staff, medical records, and equipment is called a:

Capitation

A common method of reimbursement used primarily by health maintenance organizations in which the provider or medical facility is paid a fixed, per capita amount for each individual enrolled in the plan, regardless of how many or few services the patient uses.

Open Panel IPA

A managed care system composed of individual healthcare providers who offer healthcare services for HMO and non-HMO patients, but maintain their own offices and indenties, is called a:

POS plan

A plan that allows patients to use the HMO provider or go outside the plan and pay a higher copayment and deductible is a(n):

Utilization

System designed to determine the medical necessity and appropriateness of requested medical services, procedure or hospital admission prior, concurrent or retrospective to the evvent is called:

Grievance

If a particular medical service or procedure is determined not to be "medically necessary", a patient may file a:

Preauthorization

procedure required by third pary payers that require permission before a provider can carry out specific procedure and treatments is:

An _________ provides it's members with basic healthcare services for a fixed price for a given period of time

HMO

A _______ typically do not require authorization from a PCP for a referal to a specialist.

PPO

Managed Care

A type of health coverage where the carrier is responsible for both the financing and delivery of health care

Referal

When a patient's problem exceeds the expertise of his/her PCP, the PCP can arrange a ________ specialist to take over the patient's care.

Preventive

Managed care plans emphazise _______ healthcare.

Closed Panel

staff model is this kind of hmo

Direct Contract

The ______ _______ HMO is similar to an IPA except the HMO contracts directly with the individual physicians.

IPA is a ____ ____ ____

Open Panel plan

Consultation

when the PCP sends a patient to another healthcare provider, usually a specialist, for the purpose of the consulting physician rendering his or her expert opinion regarding the patient's condition.

POS Model

A hybrid type of managed care (also refered to as an open-ended HMO) that allows patients to use the HMO provider or go outside the plan and use any provider they choose.

MCO

managed care organization

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