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mod wk 3

insurance term

copay copayment
epo exclusive provider organization
fmc foundation for medicare care
hmo health maintenance organization
ipa independent or individual practice association
mco managed care organization
pcp primary care physician
pos point of service
ppg physicians provider group
ppo preferred provider organization
ur utilization review
php prepaid health plan
buffing a physicians justifying the transference of sick, high-cost patients to other physicians in a managed care plan
capitation a system of payment used by managed care plans in which physicians and hospital are paid a fixed per capita amount for each pt enrolled over a stated period of time.
carve outs medical services not included within the capitation rate as benefits of a managed care contract and may be contracted separately
churning when physicians see a high volume of patients more than medical necessary to increase revenue
copayment a patients payment of a portion of the cost at the time service is rendered
deductible a specific dollar amount that must be paid by the insured before a medical insurance plan or government program begins converting health care cost
direct referral authorization request form is completed and signed by the physician and handed to the patient to be done directly
gatekeeper in the managed care system, this is the physician who controls patients access to specialists and diagnostic services
participating physicians a physician who contracts with an HMO or other insurance company to provide services who have agreed to accept a plan payment
tertiary services requested by a specialist from another specialist
V codes health care encounters that occur for seasons other than illness or injury or special circumstances or problems
e codes coding used to describe environmental events, circumstances, and conditions as the external cause of injury, poisoning, and other adverse effects.
accidental unexpected happening causing injury traceable to a definite time and place
benign does not have the properties of invasion of metastasis
malignant has the property of invasion and metastasis
metastasis spread of a disease producing agency (as cancer cells or bacteria) from the initial or primary site of disease to another part of the body
neoplasm any new or abnormal growth of tissue serving no physiological function
poisoning condition resulting from an overdose of drugs or chemical substances or from the wrong drug or agent given or taken in error
primary initial or identification of the condition or chief complaint
therapeutic use correct substance administered properly and as prescribed
uncertain behavior behavior of the neoplasm is unknown and cannot be ascertained until a biopsy or excision is performed
unspecified behavior diagnostic information has not specified the nature of behavior that may be known
where was the ross-loos medical group located? la
what medical group is the oldest privately owned prepaid medical group? ross-loos medical group aka-cigna
what is a closed panel program? its composed of multi specialty physicians and the plan limits the patients choice of personal physicians
what is the reason for hmo act of 1973? requiring most employers to offer hmo to their employees
what insurance company is the largest in the US? bb/bs
what is FMC (foundation for medical care)? an organization of physicians sponsored by a state or local medical association concerned with the development and delivery of medical services and the cost of health care
what is EPO (exclusive provider organization) a type of managed care plan that combines features of HMOs
are epos regulated or fedral regulations ? regulated under insurance statues
What is an IPA? physicians that are NOT employees and are NOT paid salaries. but ARE paid for their services on a capitation or fee for service basis out of a fund draw from the premium collected from subscriber, union, or corporation
what is a ppg (physicians provider group) ? a physician owned business entity that has the flexibility to deal with all forms of contract medicine and still offer its own packages to business groups, unions and the general public.
pos allows which medical group in? kaiser pts
in a pos program members choose a primary care physician who manage specialty care and referrals
what is turfing? it is to transfer the sickets, high cost patient to other physicians so that the provider appears to be a low utilizer
Is there a deductible for a managed care plan ? NO
what is fee for service? payment up front
what is staff model a type of HMO in which the health plan hires physicians directly and pays them a salary instead of contracting with a medical group
what is QIO (quality improvement organization) formerly known as professional or peer review organization, contracts with CMS to review medical necessity,
can a person who is eligible for medicare still have an HMO or prepaid health plan? YES
What is a prepaid health plan? member pays monthly premium in exchange for comprehensive care
what happens if a primary care physician sends a patient to an oot of network specialist specialist may bill the primary care physician for payment
Created by: deefuerte