22 terms

Understanding Managed care: Insurance plans

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carriers
Private insurers
Providers
The individual or facility providing medical care
Premiums
The cost of purchasing the insurance policy
Deductible
The amount the employees had to pay out of their pockets before insurance began paying
Managed care
Managed care is a method of controlling healthcare costs and ensuring that medical care is available to everyone.
Managed care organization (MCO)
Contracts with a physician or medical facility, reimbursement for each procedure is paid at a discounted fee.
Point of service (POS)
Managed care utilizes a network of providers this is true with POS plans.
Enrollee
Person enrolled in a contract with the insurance plan.
Primary care physician (PCP)
The PCP, also referred to as a gatekeeper, is the provider who coordinates a patients care.
Health Maintenance organization (HMO)
A medical center or a designated group of providers that provides medical services to subscribers
Subcribers
persons who are covered on the insurance policy
Policyholder
insured, subcriber, or member
Copayment
is a fixed dollar amount the member pays for each office visit or hospital encounter.
Coinsurance
is the portion of the provider's fees that the patient has to pay
Preferred provider organization (PPO)
Contracts with physicians and facilities to perform services for PPO members at specified rates.
Preauthorization
Written approval for treatment.
Insured
The medical office specialist needs to know if the insured person's plan is self-insured by the patients employer
Commercial health insurance
a general term for policies offered through for-profit companies such as aetna, prudential, and united health care.
Group insurance
One master policy is issued to an organization or employer and covers the eligible members or employees and their dependents.
Preexisting condition
Is a diagnosis that the insured has previously been treated for
Special risk insurance
A person can obtain protection against a certain type of accident or illness such as a plane crash or cancer
Assignment of benefits
This statement authorizes the insurance company to send paymets directly to the provider. If the provider doesnt accept assignment, the patient must pay at the time of service.