HIT Chapter 7 Vocab
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| Capitation | a reimbursement system in which healthcare providers receive a fixed fee for every patient enrolled in the plan, regardless of how many or few services the patient uses
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| Closed panel HMO | other healthcare providers in the community cannot participate
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| Consultation | when the PCP sends a patient to another healthcare provider, usually a specialist, for the purpose of the consulting physician rendering his or her expert opinion regarding the patient’s condinition.
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| Copayment | the amount of money the patient has to pay out of his or her own pocket
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| Direct contract model | similar to an IPA except the HMO contracts directly with with the individual physicians
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| Enrollees | people who are covered under a managed care plan
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| Grievance | written complaint submitted by an individual covered by the plan.
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| Group Model | the HMO contracts with independent multispecialty physician groups who provide all healthcare services to its members.
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| Health Maintenance Organization (HMO) | plan that provides healthcare to its enrollees from specific physicians and hospitals that contract with the plan
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| Iatrogenic effects | a symptom or illness brought on unintentionally to by something that the physician does or says
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| Individual Practice Association (IPA) | services are provided by outpatient networks composed of individual healthcare providers who provide all the needed healthcare
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| Managed Care | complex health care system in which physicians, hospitals, and other healthcare professionals organize an interrelated system of people and facilities that communicate with one another and work together as a unit
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| Network | an interrelated system of people and facilities that communicate with one another and work together as a unit
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| Network model | multiple provider arrangements, including staff, group, or IPA structures. Allows providers to be paid on a fee-for-service basis
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| Open panel plan | healthcare providers in the community can participate in the plan
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| Point of Service (POS) | “hybrid” type of managed care also referred to as an open ended HMO. Allows patients to use the HMO provider or go outside of the plan and use any provider that they choose.
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| Preauthorization | a procedure required by most managed care and indemnity plans before a provider carries out specific procedures or treatments for a patient
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| Precertification | process used by health insurance companies to control healthcare costs and is similar to a preauthorization.
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| Preferred Provider Organization (PPO) | A group of healthcare providers that works under an umbrella to provide medical services at a discount to the individuals who participate in the PPO
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| Primary Care Physician (PCP) | a specific provider who oversees the member’s total healthcare treatment.
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| Referral | a request by a healthcare provider for a patient under his or her care to be evaluated or treated by another provider, usually a specialist
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| Specialist | a physician who is trained in a certain area of medicine
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| Staff Model | a multispecialty group practice in which all healthcare services are provided within the buildings owned by the HMO.
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| Utilization Review | also referred to as utilization management, a system designed to determine the medical necessity and appropriateness of a requested medical service, procedure, or hospital admission prior, concurrent, or retrospective to the event
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