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MD300 Chapter 3plus
Review of Ch 3, 13, 14 terms
| Term | Definition |
|---|---|
| Identifies the patient to the insurance company | ID number |
| Identifies the patient's employer group health plan | Group number |
| A specific name assigned by the insurance company designating a specific plan for that type of insurance. | plan type |
| Traditional insurance where reimbursement is made at 80 percent of the allowed amount and the patient pays the remaining 20 percent. | Indemnity |
| Payment is made for each service provided. | Fee for Service |
| Special clauses giving additional coverage over and above the standard contract. | Riders |
| Originally provided coverage for hospital bills | Blue Cross |
| Originally provided coverage for physician bills. | Blue Shield |
| Indemnity plan for Blue Cross/Blue Shield | ClassicBlue |
| Managed Care plan for Blue Cross/Blue Shield | PPOBlue |
| Medicare Advantage plan for Blue Cross/Blue Shield | SecurityBlue |
| Medicare Part D plan for Blue Cross/Blue Shield | BlueRx |
| Medicare Supplemental Plan for Blue Cross/Blue Shield | MedigapBlue |
| A Federally funded program administered by the Centers for Medicare and Medicaid - for citizens 65 and over | Medicare |
| Pays for inpatient hospital, skilled nursing facilities, hospice care and home health | Medicare Part A |
| Pays for doctor services, outpatient hospital, durable medical equipment | Medicare Part B |
| The 2014 deductible for Medicare part B | $147 |
| Managed care plans and fee-for-service plans that are an alternative to original Medicare | Medicare Part C |
| Private prescription drug plans that helps pay for prescriptions under Medicare | Medicare Part D |
| Supplemental insurance that covers costs not reimbursed by original Medicare plan | Medigap |
| Provides payment for health care services for eligible low income individuals | Medicaid |
| Health insurance provided to active and retired military personnel and their dependents | Tricare |
| Tricare members receive their care at this facility by a Tricare-contracted civilian provider | Military Treatment Facility |
| For a premium, cardholders are eligible for a discount on medical services--it is not health insurance. | Medical Discount Card |
| Includes financing, management, and delivery of health care services | Managed Care Plan |
| Can be a health plan, hospital, physician group or health system | Managed Care Organization |
| Prepaid health care; there is a pre-established payment for all health services | Managed Care |
| Providers are prepaid monthly for members enrolled in a managed care plan; regardless of whether the patient is seen or not. | Capitation |
| Physicians that participate in a managed care plan; they supervise health care for enrollees | Primary Care Physician |
| Another term for a Primary Care Physician | Gatekeeper |
| Managed Care Plans are required to meet minimum performance standards | Quality Assurance |
| Legislation that created standards to assess managed care plans | HEDIS |
| Assesses managed care plans; creates report cards on each plan | NCQA |
| Assesses health care facilities | JCAHO |
| Controls costs by reviewing the appropriateness and necessity of care prior to admission or administration of care | Utilization review |
| Reviews the medical necessity of a procedure or service before it is done. | Preauthorization |
| It reviews the medical necessity of any tests and procedures during hospitalization | Concurrent review |
| Reviews the most cost-effective care after hospitalization | Discharge Planning |
| Develops patient care plans for complicated or chronic diagnosed cases | Case Management |
| Prevented providers from discussing all treatment options with the patient; now largely prohibited | Gag clauses |
| Offered to physicians to encourage them to keep costs down | Physician incentives |
| Provides services to enrolled members on a pre-paid basis | Health Maintenance Organization |
| Medical Care sought from participating providers within a managed care plan | In-network |
| Medical care sought from nonparticipating providers | Out-of-network |
| Group of physicians, hospitals, and providers that offer price discounts to insurance companies in exchange for more members | Preferred Provider Organization |
| Provides benefits if they receive services from network providers only | Exclusive Provider Organization |
| Patients have the freedom to use HMO providers or to self-refer out to non-HMO providers for a higher fee | Point of Service Plan |
| Provides subscribers or employees a choice of HMO, PPO, or traditional health plans | Triple Option Plan |
| another name for Triple Option Plan | Cafeteria Plan |
Created by:
Kirkster
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