A system that pays physicians a fixed amount per patient.

A Fixed amount owed by the patient up front at time of the office visit.

A Fixed amount owed by the patient before benefits will be considered for payment. (based on a fiscal or calendar year)

Professional services rendered to the patient that are paid for in full at time of service.

The Physician who manages the patients care.

Health Maintenance Organization: program where health services are rendered by a PCP and services are paid on a capitative basis

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.

Preferred Provider Organization: A group of providers that render care to both in and out of network patients.

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)

Transferring the sickest, high-cost patients to other physicians so that the provider appears as a "low-utilizer" in a managed care setting.

Management system to help control healthcare costs and to determine medical necessity.

A percentage of the monthly capitation that is retained until the end of the year to cover operating expenses.

A patient can refer him/herself to a specialist.

A physician informs the patient and via telephones contacts the specialist.

Medical group limits patients options to in network only.

Medical group where patients can choose physicians both in and out of network.

When physicians see a high volume of patients - more than medically necessary - to increase revenue.

Authorization request that is handed to the patient to take to the specialist.

Authorization request that is sent directly to the MCO (managed care organization) to determine medical necessity.

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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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