Handbook Chap 11
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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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