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Ch 11 - Vocabulary


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