link4 ch11
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| show | capitation
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| show | managed care organization
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| show | health mantenance organization
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| show | closed panel program
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| show | national committee for quality assurance
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| HEDIS ` | show 🗑
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| PCP | show 🗑
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| show | gatekeeper
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| EPO | show 🗑
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| show | foundation for medical care
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| show | independent practice association
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| PPO | show 🗑
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| PPG | show 🗑
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| POS | show 🗑
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| PSO | show 🗑
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| QIO | show 🗑
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| A program that contracts with cms to review medical necessity, reasonableness, appropriateness, and completeness and adequancy of inpatient hospital care for which additional payment is sought under the outlier provisions of the prospective payment system | show 🗑
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| show | quality improvement system for managed care
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| QISMC | show 🗑
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| This manage system is necessary to control cost in a managed care setting that determins the medical necessity for medical tests and procedures | show 🗑
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| UR | show 🗑
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| What occurs when a physician sees a patient more than medicaly necessary. | show 🗑
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| show | turfing
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| What term for making this practice look justifiable to the plan. | show 🗑
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| Medical services not included in the contract are called | show 🗑
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| What kind of referral is an authorization request is required by the MCO contract to determine medical necessity | show 🗑
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| show | direct referral
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| show | verbal referral
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| show | self-referral
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| When services are requested by a specialist from another specialist it is called | show 🗑
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| A specific dollar amount that must be paid by the insured before a medical insurance plan begins covering health care cost is known as | show 🗑
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| A patients payment of a protion of the cost at the time the service is rendered is known as | show 🗑
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| show | withhold
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| show | case rate pricing
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| If the patients services are more than a certain amount, the physician can begin asking the patient to pay is known as | show 🗑
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| show | withhold
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| show | exclusive provider organization
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| 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 is known as | show 🗑
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| A type of HMO in which a program administrator contracts with a number of physicians who agree to provide treatment to subscribers in there own office. The physician are not employees of the MCO and are not paid salaries. | show 🗑
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| A type of health benefit program in which enrollees receive the highest level of benefits when they obtain services from a physician or hospital designated by their program as a preferred provider | show 🗑
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| show | physician provider group
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| A manage care plan in which menbers are given a choice as to how to receive services, weather through an HMO, PPO, or fee-for-service plan. The decision is made at the time the service is necessary | show 🗑
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| show | managed care plan
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| show | staff model
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| show | network HMO
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| A type of managed care health plan contracts directly with private practice physicians in the community rather that intermediary such as a IPA or medical group | show 🗑
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| What designs and sponsors prepaid health programs or sets minimum benefits of coverage. | show 🗑
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| show | claims review type of foundation
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Created by:
maryce
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