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Fordney Chapter 11

Insurance Handbook for the Medical Office

QuestionAnswer
Supportive services other than routine hospital services provided by the facility, such as x-ray films and laboratory tests. ancillary services
A physician's justifying the transference of sick, high-cost patients to other physicians in a managed care plan. buffing
A system of payment used by managed care plans in which physicians 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. capitation
Medical services not included within the capitation rate as benefits of a manged care contract and may be contracted for separately. carve outs
When physicians see a high volume of patients - more than medically necessary - to increase revenue. May be seen in fee-for-service or managed care environments. churning
A type of foundation that provides peer review by physicians to the numerous fiscal agents or carriers involved in its area. claims-review type of foundation
A form of HMO that limits the patient's choice of personal physicians to only those doctors practicing in the HMO group practice within the geographic location or facility. A physician must meet narrow criteria to join. closed panel program
A type of foundation that designs and sponsors prepaid health programs or sets minimum benefits of coverage. comprehensive type of foundation
A patient's payment of a portion of the cost at the time of a medical service is rendered. copayment (copay)
A specific dollar amount that must be paid by the insured before a medical insurance plan or government program begins covering health care costs. deductible
Certain services in a managed care plan may not require preauthorization. The authorization request form is completed and signed by the physician and handed to the patient to be done directly. direct referral
A member's voluntary cancellation of membership in a manged care plan. disenrollment
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. These are regulated under state health insurance laws. exclusive provider organization (EPO)
A method of payment in which the patient pays the physician for each professional service performed from an established schedule to fees. fee-for-service
An authorization request required by the managed care organization contract to determine medical necessity and grant permission before services re rendered or procedures performed. formal referral
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. foundation for medical care (FMC)
In the managed care system, this is the physician who controls patient access to specialists and diagnostic testing services. gatekeeper
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 to enrollees. health maintenance organization (HMO)
Within the geographic boundaries defined by an HMO as the area in which it will provide medical services to its members. in-area
A type of HMO in which a program administrator contracts with a number of physicians who agree to provide treatment to subscribers in their own offices. Physicians are not employees of the managed care organization and are not paid salaries. independent (or individual) practice association (IPA)
A generic term applied to managed care plan. May apply to EPO, HMO, PPO, integrated delivery system, or other different managed care arrangement. Are usually prepaid group plans, and physicians are typically paid by the capitation method. managed care organizations (MCOs)
A physician who contracts with an HMO or other insurance company to provide services. The physician has agreed to accept a plan's payments for services to subscribers. participating physician
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. physician provider group (PPG)
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. The decision is made at the time of service in necessary. Sometimes referred to as open-ended HMOs. point-of-service (POS) plan
A type of health benefit program in which enrollees receive the highest level of benefits when they obtain services from a physician, hospital, or other health care provider designated by their program as preferred. preferred provider organization(PPO)
A plan under which specified health services are rendered by participation physicians to an enrolled group of persons, with fixed periodic payments made in advance, by or on behalf of each person or family. prepaid group practice model
A physician who oversees the care of patients in a manged health care plan and refers patients to see specialists for services as needed. Also known as a gatekeeper. primary care physician (PCP)
A patient in a managed care plan that refers themselves to a specialist. The patient may be required to inform the primary care physician. self-referral
The geographic are defined by an HMO as the locale in which it will provide health care services to its members directly through its own resources or arrangements with other providers in the area. service area
The type of HMO in which the health plan hires physicians directly and pays them a salary staff model
An agreement between a managed care company and a reinsurer in which absorption of prepaid patient expenses is limited; or limiting losses on an individual expensive hospital claim or professional service claim. stop-loss
Services requested by a specialist from another specialist. tertiary care
Transferring the sickest, high-cost patients to other physicians so that the provider appears as a "low-utilizer" in a managed care setting. turfing
A process of reviewing and controlling the medical necessity for reviewing and controlling the medical necessity for services and providers' use of medical care resources. utilization review (UR)
A primary care physician informs the patient and telephones to the referring physician that the patient is being referred for an appointment. verbal referral
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 physician exceeds utilization norms, he or she will not receive it. withhold
EBF Employee Benefit Plan
EPO Exclusive Provider Organization
ERISA Employee Retirement Income Security Act
FMC Foundation for Medical Care
HEDIS Health Plan Employer Data Information Set
NCQA National Committee for Quality Assurance
QIO Quality Improvement Organization program
QISMC Quality Improvement System for Managed Care
Created by: Emily Murphy Emily Murphy on 2011-11-22



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