Mod 6 Blues & MCO Word Scramble

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Question	Answer
MCO stands for what?	managed care organization
In addition to HMO's, other types of prepaid group practice models that use a managed care approach are operated by what?	MCO's - managed care organization
Capitation	a systgem of payment used by managed care plans in which physicians and hospitals are paid a fixed per capita amount for each patient enrolled over a stated period of time regardless of the type and # of services provided.
Medicare and Medicaid beneficiaries also may become members of what whether retired or employed?	managed care plans
primary care physician	also called gatekeeper; a physician who controls patient access to specialists and diagnostic testing services.
what was the usual method of billing by physicians in private practice before capitation?	fee-for-service
Name four types of HMO models	1. Prepaid Group Practice Model 2. Staff Model 3. Network HMO 4. Direct Contract HMO
exclusive provider organization	type of managed care that combines features of HMO's and PPO's
foundation for medical care	an organization of physicians sponsored by a state or local medical association
Name two basic types of foundations for medical care operations	1. comprehensive type 2. claims-review type
IPA	independent practice association; another type of MCO in which the physicians are not employees and are not paid salaries; paid by capitation or fee-for-service from premiums collected; a withhold is used to cover costs of operating the IPA
PPO	preferred provider organization; type of managed care plan where physicians provide services at a discount to patients who are members of the plan
POS	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
Provider-sponsored organization	PSO - managed care plan that is owned and operated by a hospital and provider group instead of an insurance company
If a medical plan is paid by the employer the plan is regulated by what?	ERISA - the employee retirement income security act - regulated by DOL
QIO	Quality Improvement Organization - performs reviews on medical necessity - formerly known as professional or peer review.
A peer review is an evaluation of what rendered by a practicing physician or physicians within a specialty group?	the quality and efficiency of services
carve out	medical services not included in the contract benefits - can be contracted for separately
preauthorization	required by some managed care plans for certain services or referral for patient to see a specialist.
What are 4 types of referrals?	1. Formal referral 2. direct referral 3. verbal referral 4. self referral
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	True
a managed care plan where a specialist bills the PCP encourages PCP's to do what?	to not refer patients to specialists not on the plan so that he or she can retain profits
network facilities	many managed care plans require patients have lab or radiology studies performed at plan-specified facilities
copayment	fixed fee paid by the patient to the provider at the time of service
stop-loss limit	if a patient's services are more than a certain amount, the physician can begin asking the patient to pay for services.
withhold	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
when a prepaid group practice plan limits the patient's choice of personal physicians this is termed what?	a closed panel program
in a managed care setting, a physician who controls patient access to specialists and diagnostic testing services is known as what?	gatekeeper or PCP
what are 3 systems that allow for better negotiations for contracts with large employers?	1. Managed care organizations 2. physician hospital organizations 3. group practice accepting a variety of MCO's
the oldest type of the prepaid health plans is what?	HMO
name 4 type3s of HMO models	1. Prepaid group practice model 2. staff model 3. network model 4. direct contract model
what is a 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 cost of health care.
name two types of operations used by a foundation of medical care	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
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?	PPO
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	point of service
an organization that reviews medical necessity, reasonableness, appropriateness and completeness of inpatient hospital care is called what?	quality improvement organization or peer review
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?	utilization review
what is the meaning of a "stop-loss" provision that might appear in a managed care contract?	if the patient's services are more than a certain amount the physician can begin asking the patient to pay
quality improvement organization (QIO) does what?	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
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?	EPO -exclusive provider organization
medical services not included in a managed care contract's capitation rate but that may be contracted for separately are referred to as	carve outs
when the PCP informs the patient and telephones the referring physician that the patient is being referred for an appointment, this is called what?	verbal referral
plan-specified facilities listed in managed care plan contracts where patients are required to have lab and x-ray tests done are called what?	network facilities
True or False: an HMO can be sponsored and operated by a foundation	true
True or False: a quality improvement organization determines the quality and operation of health care	true
True or false: an employer may offer the services of an HMO clinic if he or she has five or more employees	false
True or False: Medicare and Medicaid beneficiaries may not join an HMO	false
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	false

Created by: mpeoples