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Ch 11 - Vocabulary
Vocabulary
| Term | Definition |
|---|---|
| Capitation | A system that pays physicians a fixed amount per patient. |
| Copayment | A Fixed amount owed by the patient up front at time of the office visit. |
| Deductible | A Fixed amount owed by the patient before benefits will be considered for payment. (based on a fiscal or calendar year) |
| Fee For Service | Professional services rendered to the patient that are paid for in full at time of service. |
| Gatekeeper/PCP | The Physician who manages the patients care. |
| HMO | Health Maintenance Organization: program where health services are rendered by a PCP and services are paid on a capitative basis |
| IPA | Independent or individual practice association: Paid on capitation or fee for service basis and non physician owned. |
| Participating Physician | A physician who contracts with a third party or government payer and paid according to the fee schedule. |
| PPO | Preferred Provider Organization: A group of providers that render care to both in and out of network patients. |
| 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) |
| 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 | Management system to help control healthcare costs and to determine medical necessity. |
| Withhold | A percentage of the monthly capitation that is retained until the end of the year to cover operating expenses. |
| Self Refferal | A patient can refer him/herself to a specialist. |
| Verbal Referral | A physician informs the patient and via telephones contacts the specialist. |
| Closed Panel HMO | Medical group limits patients options to in network only. |
| Open Panel | Medical group where patients can choose physicians both in and out of network. |
| Churning | When physicians see a high volume of patients - more than medically necessary - to increase revenue. |
| Direct Referral | Authorization request that is handed to the patient to take to the specialist. |
| Formal Referral | Authorization request that is sent directly to the MCO (managed care organization) to determine medical necessity. |
Created by:
RacheleCarter
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