insurance term
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each of the black spaces below before clicking
on it to display the answer.
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| copay | copayment
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| epo | exclusive provider organization
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| fmc | foundation for medicare care
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| hmo | health maintenance organization
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| ipa | independent or individual practice association
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| mco | managed care organization
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| pcp | primary care physician
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| pos | point of service
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| ppg | physicians provider group
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| ppo | preferred provider organization
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| ur | utilization review
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| php | prepaid health plan
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| buffing | a physicians justifying the transference of sick, high-cost patients to other physicians in a managed care plan
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| 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.
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| carve outs | medical services not included within the capitation rate as benefits of a managed care contract and may be contracted separately
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| churning | when physicians see a high volume of patients more than medical necessary to increase revenue
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| copayment | a patients payment of a portion of the cost at the time service is rendered
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| 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
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| direct referral | authorization request form is completed and signed by the physician and handed to the patient to be done directly
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| gatekeeper | in the managed care system, this is the physician who controls patients access to specialists and diagnostic services
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| participating physicians | a physician who contracts with an HMO or other insurance company to provide services who have agreed to accept a plan payment
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| tertiary | services requested by a specialist from another specialist
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| V codes | health care encounters that occur for seasons other than illness or injury or special circumstances or problems
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| e codes | coding used to describe environmental events, circumstances, and conditions as the external cause of injury, poisoning, and other adverse effects.
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| accidental | unexpected happening causing injury traceable to a definite time and place
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| benign | does not have the properties of invasion of metastasis
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| malignant | has the property of invasion and metastasis
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| 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
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| neoplasm | any new or abnormal growth of tissue serving no physiological function
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| poisoning | condition resulting from an overdose of drugs or chemical substances or from the wrong drug or agent given or taken in error
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| primary | initial or identification of the condition or chief complaint
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| therapeutic use | correct substance administered properly and as prescribed
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| uncertain behavior | behavior of the neoplasm is unknown and cannot be ascertained until a biopsy or excision is performed
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| unspecified behavior | diagnostic information has not specified the nature of behavior that may be known
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| where was the ross-loos medical group located? | la
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| what medical group is the oldest privately owned prepaid medical group? | ross-loos medical group aka-cigna
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| what is a closed panel program? | its composed of multi specialty physicians and the plan limits the patients choice of personal physicians
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| what is the reason for hmo act of 1973? | requiring most employers to offer hmo to their employees
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| what insurance company is the largest in the US? | bb/bs
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| 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
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| what is EPO (exclusive provider organization) | a type of managed care plan that combines features of HMOs
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| are epos regulated or fedral regulations ? | regulated under insurance statues
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| 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
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| 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.
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| pos allows which medical group in? | kaiser pts
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| in a pos program | members choose a primary care physician who manage specialty care and referrals
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| 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
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| Is there a deductible for a managed care plan ? | NO
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| what is fee for service? | payment up front
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| 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
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| what is QIO (quality improvement organization) | formerly known as professional or peer review organization, contracts with CMS to review medical necessity,
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| can a person who is eligible for medicare still have an HMO or prepaid health plan? | YES
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| What is a prepaid health plan? | member pays monthly premium in exchange for comprehensive care
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| 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
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