Handbook Chap 11
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| MCO stands for what? | show 🗑
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| show | MCO's - managed care organization
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| Capitation | show 🗑
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| Medicare and Medicaid beneficiaries also may become members of what whether retired or employed? | show 🗑
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| primary care physician | show 🗑
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| what was the usual method of billing by physicians in private practice before capitation? | show 🗑
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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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| Name two basic types of foundations for medical care operations | show 🗑
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| IPA | show 🗑
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| PPO | show 🗑
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| show | point of service plan - combines elements of HMO and a PPO while offering some unique features; allows patient to choose service from either an HMO provider or PPO provider
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| Provider-sponsored organization | show 🗑
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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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| show | 1. Formal referral
2. direct referral
3. verbal referral
4. self referral
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| show | True
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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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| withhold | show 🗑
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| show | a closed panel program
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| in a managed care setting, a physician who controls patient access to specialists and diagnostic testing services is known as what? | show 🗑
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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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| show | 1. comprehensive type-designs & sponsors prepaid health plans or sets of minimum benefits
2. claims review types - provides evaluation of the quality and efficiency of services
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| a health benefit program in which enrollees may choose any physician or hospital for services but obtain a higher level of benefits if preferred providers are used is known as what? | show 🗑
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| show | point of service
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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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| show | utilization review
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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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| show | 1. examines evidence for admission and discharge of a patient from the hospital
2. evaluates the quality and efficiency of services rendered by a practicing physician or physicians in a specialty group
3. settles disputes over fees
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| show | EPO -exclusive provider organization
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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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| True or false: an employer may offer the services of an HMO clinic if he or she has five or more employees | show 🗑
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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:
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