Ch. 11 Terms

Question 1

Ancilliary services

Answer 1

Supportive services other than routine hospital services provided by the facility, such as x ray films and lab tests.

Question 2

Buffing

Answer 2

A doctor’s justifying the transference of sick, high cost patient’s to other doctors in a managed care plan.

Question 3

Capitation

Answer 3

A system of payment used by managed care plans in which doctors and hospitals are paid a fixed per capita amount for each patient enrolled over a stated period of time, regardless of the type and number of services provided; reimbursement to the hospital on a per member/per month basis to cover costs for the members of the plan. Capitation also can mean a set amount to be paid per claim.

Question 4

Carve outs

Answer 4

Medical services not included within the capitation rate as benefits of a managed care contract and may be contracted for separately

Question 5

Churning

Answer 5

When doctors see a high volume of patients - more than medically necessary - to increase revenue. May be seen in fee for service or managed care environments.

Question 6

Claims review type of foundation

Answer 6

A type of foundation that provides peer review by doctors to the numerous fiscal agents or carriers involved in its area

Question 7

Closed panel program

Answer 7

A form of HMO that limits the patient’s choice of personal doctors to only those doctors practicing in the HMO group practice within the geographic location or facility. A doctor must meet narrow criteria to join a closed panel

Question 8

Comprehensive type of foundation

Answer 8

A type of foundation that designs and sponsors prepaid health programs or sets minimum benefits of coverage

Question 9

Copayment

Answer 9

A patient’s payment of a portion of the cost at the time the service is rendered; sometimes called coinsurance.

Question 10

Deductible

Answer 10

A dollar amount that must be paid before a medical insurance plan begins covering costs

Question 11

Direct referral

Answer 11

Certain services in a managed care plan may not require authorization. The auth request form is completed and signed by the doctor and handed to the patient to be done directly

Question 12

Disenrollment

Answer 12

A member’s voluntary cancellation of membership in a managed care plan

Question 13

Exclusive provider organization

Answer 13

(EPO) A type of managed health plan that combines features of HMOs and PPOs. It’s called “exclusive” because it’s offered to large employers who agree not to contract with any other plan. EPOs are regulated under state health insurance laws

Question 14

Fee for service

Answer 14

A method of payment in which the patient pays the doctor for each professional service performed from an established schedule of fees

Question 15

Formal referral

Answer 15

An authorization request required by the managed care organization contract to determine medical necessity and grant permission before services are rendered or procedures performed

Question 16

Foundation for medical care

Answer 16

A group of doctors sponsored by a state or local medical association concerned with the development and delivery of medical services and the cost of health care

Question 17

Gatekeeper

Answer 17

This is the doctor who controls patient access to specialists and diagnostic testing services

Question 18

Health Maintenance Organization

Answer 18

The oldest of all prepaid health plans. A comprehensive health care financing and delivery organization that provides a wide range of health care services with an emphasis on preventive medicine to enrollees within a geographic area through a panel of providers. Primary care doctor “gatekeepers” are usually reimbursed via capitation. In general, enrollees don’t receive coverage for the services from providers who aren’t in the HMO network, except for emergency services

Question 19

In- area

Answer 19

Within the geographic boundaries defined by an HMO as the area in which it will provide medical services to its members

Question 20

Independent (or individual) practice association

Answer 20

A type of HMO in which a program administrator contracts with a number of doctors who agree to provide treatment to subscribers in their own offices. Doctors aren’t employees of the managed care organization (MCO) and aren’t paid salaries. They receive reimbursement on a capitation or fee for service basis; also referred to as a medical capitation plan.

Question 21

Managed care organizations (MCO)

Answer 21

A generic term applied to a managed care plan. May apply to EPO, HMO, PPO, integrated delivery system, or other different managed care arrangement. MCOs are usually prepaid group plans and doctors are typically paid by the capitation method.

Question 22

Participating physician

Answer 22

A doctor who agrees to accept payment from Medicare (80% of the approved charges) plus payment from the patient (20% of approved charges) after the $100 deductible has been met

Question 23

Per capita

Answer 23

See definition of Capitation

Question 24

Physician provider group

Answer 24

A doctor owned business 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.

Question 25

Point of service plan

Answer 25

A managed care plan in which members are given a choice as to how to receive services, whether through an HMO, PPO, or FFS plan. The decision is made at the time the service is necessary (ex: at the point of service”); sometimes referred to as open ended HMOs, swing-out HMOs, self referral options, or multiple option plans

Question 26

Preferred provider organization (PPO)

Answer 26

A type of health benefit program in which enrollees receive the highest level of benefits when they obtain services from a doctor, hospital, or other health care provider designated by their program as a “preferred provider”. Enrollees may receive substantial, although reduced, benefits when they obtain care from a provider of their own choosing who isn’t designated as a “preferred provider” by their program.

Question 27

Primary care physician

Answer 27

Also known as a gatekeeper, this is a doctor who oversees the care of patients in a managed health care plan (HMO or PPO) and refers patients to see specialists.

Question 28

Self referral

Answer 28

A patient in a managed care plan that refers himself to a specialist. The patient may be required to inform the primary care doctor.

Question 29

Service area

Answer 29

The geographic area defined by an HMO as the locale in which it will provide health care services to its members directly through its own resources or arrangements with other providers in the area

Question 30

Staff model

Answer 30

The type of HMO in which the health plan hires doctors directly and pays them a salary.

Question 31

Stop loss

Answer 31

An agreement between a managed care company and a reinsurer in which absorption of prepaid patient expenses is limited; or limiting losses on an individual expensive hospital claim or professional services claim; a form of reinsurance by which the managed care program limits the losses of an individual expensive hospital claim

Question 32

Tertiary care

Answer 32

Services requested by a specialist from another specialist

Question 33

Turfing

Answer 33

Transferring the sickest, high cost patients to other doctors so that the provider appears as a “low utilizer” in a managed care setting.

Question 34

Utilization review

Answer 34

A process, based on established criteria, of reviewing and controlling the medical necessity for services and providers use of medical care resources. Reviews are carried out by allied health personnel at predetermined times during the hospital stay to assess the need for the full facilities of an acute care hospital. In managed care systems such as an HMO, reviews are done to establish medical necessity, thus curbing costs. Also called utilization or management control.

Question 35

Verbal referral

Answer 35

A primary care doctor informs the patient and telephones to the referring doctor that the patient is being referred for an appointment

Question 36

Withold

Answer 36

A portion of the monthly capitation payment to doctors retained by the HMO until the end of the year to create an incentive for efficient care. If the doctor exceeds utilization norms, he or she will not receive it.