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Handbook Chap 11

Quiz yourself by thinking what should be in each of the black spaces below before clicking on it to display the answer.
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Question
Answer
show managed care organization  
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In addition to HMO's, other types of prepaid group practice models that use a managed care approach are operated by what?   show
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Capitation   show
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show managed care plans  
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show also called gatekeeper; a physician who controls patient access to specialists and diagnostic testing services.  
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show fee-for-service  
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show 1. Prepaid Group Practice Model 2. Staff Model 3. Network HMO 4. Direct Contract HMO  
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show type of managed care that combines features of HMO's and PPO's  
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foundation for medical care   show
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show 1. comprehensive type 2. claims-review type  
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IPA   show
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PPO   show
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POS   show
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show PSO - managed care plan that is owned and operated by a hospital and provider group instead of an insurance company  
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show ERISA - the employee retirement income security act - regulated by DOL  
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show Quality Improvement Organization - performs reviews on medical necessity - formerly known as professional or peer review.  
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A peer review is an evaluation of what rendered by a practicing physician or physicians within a specialty group?   show
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show medical services not included in the contract benefits - can be contracted for separately  
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show required by some managed care plans for certain services or referral for patient to see a specialist.  
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What are 4 types of referrals?   show
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True or False: In some managed care plans, when a PCP sends a patient to a specialist for consultation who is not in the plan, the specialist bills the PCP   show
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show to not refer patients to specialists not on the plan so that he or she can retain profits  
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network facilities   show
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show fixed fee paid by the patient to the provider at the time of service  
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stop-loss limit   show
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show in a managed care plan, is the percentage of the monthly capitation payment retained or percentage of the allowable charges to physicians until the end of the year to cover operating expenses  
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show a closed panel program  
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show gatekeeper or PCP  
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what are 3 systems that allow for better negotiations for contracts with large employers?   show
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the oldest type of the prepaid health plans is what?   show
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show 1. Prepaid group practice model 2. staff model 3. network model 4. direct contract model  
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show an organization of physicians sponsored by a state or local medical association concerned with the development and delivery of medical services and cost of health care.  
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name two types of operations used by a foundation of medical care   show
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show PPO  
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HMO's and PPO's consisting of a network of physicians and hospitals that provide an insurance company or employer with discounts on their services are referred to collectively as what   show
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an organization that reviews medical necessity, reasonableness, appropriateness and completeness of inpatient hospital care is called what?   show
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to control health care costs, the process of reviewing and establishing medical necessity for services and providers' use of medical care resources is called what?   show
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show if the patient's services are more than a certain amount the physician can begin asking the patient to pay  
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quality improvement organization (QIO) does what?   show
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a type of managed care plan regulated unmder insurance laws combining features of HMO's and PPO's that employers agree not to contract with any other plan is known as what?   show
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medical services not included in a managed care contract's capitation rate but that may be contracted for separately are referred to as   show
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show verbal referral  
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plan-specified facilities listed in managed care plan contracts where patients are required to have lab and x-ray tests done are called what?   show
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True or False: an HMO can be sponsored and operated by a foundation   show
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show true  
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show false  
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True or False: Medicare and Medicaid beneficiaries may not join an HMO   show
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True or false: withheld managed care amounts that are not yet received from the managed care plan by the medical practice should be shown as a write-off in an accounts journal   show
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Created by: mpeoples