Ch. 11 Terms Flashcards
Ancilliary services
Supportive services other than routine hospital services provided by the facility, such as x ray films and lab tests.
Buffing
A doctor’s justifying the transference of sick, high cost patient’s to other doctors in a managed care plan.
Capitation
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.
Carve outs
Medical services not included within the capitation rate as benefits of a managed care contract and may be contracted for separately
Churning
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.
Claims review type of foundation
A type of foundation that provides peer review by doctors to the numerous fiscal agents or carriers involved in its area
Closed panel program
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
Comprehensive type of foundation
A type of foundation that designs and sponsors prepaid health programs or sets minimum benefits of coverage
Copayment
A patient’s payment of a portion of the cost at the time the service is rendered; sometimes called coinsurance.
Deductible
A dollar amount that must be paid before a medical insurance plan begins covering costs
Direct referral
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
Disenrollment
A member’s voluntary cancellation of membership in a managed care plan
Exclusive provider organization
(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
Fee for service
A method of payment in which the patient pays the doctor for each professional service performed from an established schedule of fees
Formal referral
An authorization request required by the managed care organization contract to determine medical necessity and grant permission before services are rendered or procedures performed
Foundation for medical care
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
Gatekeeper
This is the doctor who controls patient access to specialists and diagnostic testing services
Health Maintenance Organization
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
In- area
Within the geographic boundaries defined by an HMO as the area in which it will provide medical services to its members
Independent (or individual) practice association
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.
Managed care organizations (MCO)
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.
Participating physician
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
Per capita
See definition of Capitation
Physician provider group
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.
