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mod wk 3
insurance term
| Question | Answer |
|---|---|
| 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
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