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15 terms

CH 11

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Capitation
If a patient or hospital in a managed care plan is paid a fixed, per capita amount for each patient rnrolled regardless of the type and number if services rendered, this is a payment system known as?
Gatekeeper
In a managed care setting, a physician who controls patients access to specialists and diagnostic testing services is known as a?
HMO
The oldest type of the prepaid health plan is ?
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?
POS
HMO's and preferred provider organizations (PPO's) consisting of a network of physicians and hospitals that provide and insurance company or emoloyer with discounts on their services are referred to collectively as a?
QIO
An organization that reviews medical necessity, reasonableness, appropriateness, and completeness of inpatient hospital care is called ?
QIO
_____ is responsible for examining evidence for admission and discharge or pt from the hospital; evaluation the quality and efficiency of services rendered by physician and settles disputes over fees
Exclusive Provider Organization (EPO)
A type of managed care plan regulated under insurance statues comining features of HMO and PPO's that employers agree not to contract with any other plan is known as?
Carve Outs
Medical services not included within the capitation rate as benefits of a managed care contract and may be contracted for separately.
Verbal Referral
When a primary care physician informs the patient and telephones the referring physician that the patient is being referred for an appointment is called?
TRUE
T/F An HMO can be sponsored and operated by a foundation
TRUE
T/F A Quality Improvement Organization determines the quality and operation of health care
FALSE
T/F AN employer may offer the services of an HMO clinic if he or she has five or more employees
FALSE
T/F Medicare and Medicaid beneficiaries may not join an HMO
FALSE
T/F Withheld managed care amounts that are not yet received from the managed care play by the medical practice should be known as a write-off in an accounts journal.