Vocabulary
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Capitation | A system that pays physicians a fixed amount per patient.
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| Copayment | A Fixed amount owed by the patient up front at time of the office visit.
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| Deductible | A Fixed amount owed by the patient before benefits will be considered for payment.
(based on a fiscal or calendar year)
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| Fee For Service | Professional services rendered to the patient that are paid for in full at time of service.
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| Gatekeeper/PCP | The Physician who manages the patients care.
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| HMO | Health Maintenance Organization: program where health services are rendered by a PCP and services are paid on a capitative basis
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| IPA | Independent or individual practice association: Paid on capitation or fee for service basis and non physician owned.
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| Participating Physician | A physician who contracts with a third party or government payer and paid according to the fee schedule.
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| PPO | Preferred Provider Organization: A group of providers that render care to both in and out of network patients.
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| Stop Loss | Patient services are more than a specific amount the physician can ask the patient for the additional payment.
(has to be written into there contract)
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| Turfing | Transferring the sickest, high-cost patients to other physicians so that the provider appears as a "low-utilizer" in a managed care setting.
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| Utilization Review | Management system to help control healthcare costs and to determine medical necessity.
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| Withhold | A percentage of the monthly capitation that is retained until the end of the year to cover operating expenses.
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| Self Refferal | A patient can refer him/herself to a specialist.
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| Verbal Referral | A physician informs the patient and via telephones contacts the specialist.
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| Closed Panel HMO | Medical group limits patients options to in network only.
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| Open Panel | Medical group where patients can choose physicians both in and out of network.
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| Churning | When physicians see a high volume of patients - more than medically necessary - to increase revenue.
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| Direct Referral | Authorization request that is handed to the patient to take to the specialist.
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| Formal Referral | Authorization request that is sent directly to the MCO (managed care organization) to determine medical necessity.
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Created by:
RacheleCarter
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