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IHMO Chapter 11 SRC

Key Terms

Ancillary Services Supportive services other than routine hospital services provided by the facility, such as x-rays & lab tests
Buffing A physicians justifying the transference of sick, high-cost patients to other physicians in a managed care plan
Capitation A system of payment used by managed care plans in which Dr's and hospitals are paid a fixed per capita amount for each patient enrolled over a stated period of time, regardless of the type and number of services provided.
Carve outs Medical services not included within the capitation rate as benefits of a managed care contract and may be contracted out separately
Churning When Dr's see a high volume of patients-more than medically necessary-to increase revenue. May be seen in fee-for-service or MC environments
Claims-review type of foundation A type of foundation that provides peer review by physicians to the numerous fiscal agents or carriers involved in its area
Closed panel program Form of HMO that limits the patient's choice of personal doctors to only those Dr's practicing in the HMO group practice within the geographic location or facility. A Dr. must meet narrow criteria to join a closed panel.
Comprehensive type of foundation Type of foundation that designs and sponsors prepaid health programs or sets minimum benefits of coverage
co payment a patient's payment of a portion of the cost at the time the services rendered sometimes referred to as coinsurance
deductible a specific dollar amount that must be paid by the insured before a medical insurance plan or government program begins covering health care costs
direct referral certain services in a managed care plan may not require preauthorization. The request form is completed and signed by the Dr. and handed to the patient to be done directly.
Disenrollment a members voluntary cancellation of membership in a managed care plan.
Exclusive provider organization ( EPO) A type of managed health care plan that combines features of HMOs and PPOs. It is referred to as "exclusive" because it is offered to large employers who agree not to contract with any other plan. EPO's are regulated under state health insurance laws
fee for service a method of payment which the patient pays the physician for each professional service performed from an established schedule of fees.
Formal referral an authorization request required by the MCO contract to determine medical necessity and grant permission for services are rendered.
foundation for medical care ( FMC) 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 the health care
gate keeper In the managed care system, this is the physician who controls patient access to specialist and diagnostic testing services.
HMO health maintenance organization the oldest of all prepaid health plans. A comprehensive health care financing and delivery organization that provides a wide range of health care services with an emphasis on preventative medicine.
in area within the geographic boundaries defined by an HMO as the area in which it will provide medical services to its members
Independent practice Association – IPA type of HMO in which a program administrator contracts with a number of doctors who agree to provide treatment to subscribers in their own offices. They receive reimbursement on a capitation or fee-for-service basis
managed-care organizations – MCO a generic term applied to a managed care plan may apply to EPO, HMO, PPO. MCO's are usually prepaid group plans. Doctors are typically paid by the capitation method.
Participating physicians a physician who contracts within a HMO or other insurance company to provide services. A physician who has agreed to accept the plans payment for services to subscribers. 80% of practicing American doctors are participating physicians
physician provider group – PPG a physician owned business that has the flexibility to deal with all forms of contract medicine and still offer its own packages to business groups, unions, and the general public.
Point of service – POS plan a managed care plan in which members are given a choice as to how to receive services, whether through an HMO, PPO or fee-for-service plan. Sometimes referred to as open ended HMO
prepaid group practice model a plan under which specific health services are rendered by participating doctors to an enrolled group of persons, with fixed periodic payments made in advance, by or on behalf of each person or family.
Self referral a patient in a managed care plan that refers himself or herself to a specialist. The patient may be required to inform the primary care physician
staff model the type of HMO in which the health plan hires physicians directly and pays them a salary
stop-loss an agreement between a managed care company and a re insurer in which absorption of prepaid patients expenses is limited; or limiting losses on an individual expensive hospital claim
tertiary care services requested by a specialist from another specialist
turfing transferring the sickest, high-cost patients to other physicians so that the provider appears as a "low utilizer" in a managed care setting
utilization review-UR a process, based on established criteria, of reviewing and controlling the medical necessity for services and providers use of medical care resources.
Verbal referral a primary care physician informs the patient and telephones to the referring physician that the patient is being referred for an appointment
Withhold a portion of the monthly capitation payment to physicians retained by the HMO until the end of the year to create an incentive for efficient care. If the doctor exceeds utilization norms, they will not receive it.
Created by: src1063