insurance hand book chapter #11

24 terms by aracelicanela

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capitation.

If a physician or hospital in a managed care plan is paid a fixed, per capita amount for each patient enrolled regardless of the type and number of services rendered, this is a payment system known as

closed panel

When a prepaid group practice plan limits the patient's choice of personal physicians, this is termed a/an

gatekeeper

In a managed care setting, a physician who controls patient access to specialists and diagnostic testing services is known as a/an

a. managed care organizations (MCOs).
b. physician-hospital organizations.
c. group practices accepting a variety of MCOs and fee-for-service patients

Systems that allow for better negotiations for contracts with large employers are

health maintenance organizations (HMOs).

The oldest type of the prepaid health plans is

a. prepaid group practice model
b. staff model
c. network HMO
d. direct contract model

Name four types of health maintenance organization (HMO) models

An organization of physicians sponsored by a state or local medical association concerned with the development and delivery of medical services and the cost of health care.

. What is a foundation for medical care?

a. Comprehensive type: designs and sponsors prepaid health programs or sets minimum benefits of coverage.
b. Claims-review type: a panel of physicians which provides evaluation of the quality and efficiency of services to the numerous fiscal agents involved in its area, including the ones processing Medicare and Medicaid.

. Name two types of operations used by foundations for medical care, and explain the main feature of each.

preferred provider organization (PPO).

A health benefit program in which enrollees may choose any physician or hospital for services but obtain a higher level of benefits if preferred providers are used is known as a/an

point-of-service (POS) plan

HMOs and preferred provider organizations (PPOs) consisting of a network of physicians and hospitals that provide an insurance company or employer with discounts on their services are referred to collectively as a/an

Quality Improvement Organization (QIO).

An organization that reviews medical necessity, reasonableness, appropriateness, and completeness of inpatient hospital care is called a/an

utilization review

To control healthcare costs, the process of reviewing and establishing medical necessity for services and providers' use of medical care resources is termed

. If the patient's services exceed a certain cost, then the physician may ask the patient to pay.

Explain the meaning of a "stop-loss" provision that might appear in a managed care contract

withhold.
Part II Multiple Choice Questions

When a certain percentage of the monthly capitation payment or a percentage of the allowable charges to physicians is set aside to operate a managed care plan, this is known as a/an

examines evidence for admimssion and discharge of a patient from the hospital.
b. evaluates the quality and efficiency of services rendered by a practicing physician or physicians within a specialty group.
c. settles disputes over fees.

. A Quality Improvement Organization (QIO)

exclusive provider organization (EPO).

A type of managed care plan regulated under insurance statutes combining features of health maintenance organizations and preferred provider organizations that employers agree not to contract with any other plan is known as

carve outs.

Medical services not included in a managed care contract's capitation rate but that may be contracted for separately, are referred to as

verbal referral.

When the primary care physician informs the patient and telephones the referring physician that the patient is being referred for an appointment, this is called a/an

network facilities

Plan-specified facilities listed in managed care plan contractsPlan-specified facilities listed in managed care plan contracts requiring patients to have laboratory and radiology tests performed are called

true

an HMO can be sponsored and operated by a foundation

true

a quality improvement organization determines the quality and operation of health care

false

an employee may offer the services of an HMO clinic if he or she has five or more employees

false

medicare and medicaid beneficiaries may not join an HMO

false

withheld managed care amounts that are not yet recived from the managed care plan by the medical practice should be shown as a write-off in an accounts journal

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