Ch 13 - Healthcare Business and Operations

Question 1

Associate Practice

Answer 1

A legal agreement in which physicians share staff and overhead expenses of operation but do not share in the legal responsibility or in the profits of the business.

Question 2

CHAMPVA

Answer 2

Acronym denoting Civilian Health and Medical Program of the Department of Veterans Affairs. Coverage designed specifically for disabled veterans and their dependents. Also known as Veterans Health Administration.

Question 3

Coinsurance

Answer 3

The percentage of payment that is agreed on by the insured as their portion of any claims; cost-sharing.

Question 4

Copay

Answer 4

A fixed amount determined by the health insurance policy that is paid for services to offset premiums paid by the insured.

Question 5

Corporation

Answer 5

A company that is established legally and is managed by a board of directors.

Question 6

Deductible

Answer 6

An amount of money that is paid by the insured before the insurance company pays for services. Usually a fixed amount paid annually.

Question 7

Gatekeeper

Answer 7

A person, such as the primary care physician, or an organization that is appointed by a managed care carrier to maintain and approve services to reduce costs and unnecessary spending.

Question 8

Group practice

Answer 8

A medical practice with three or more physicians of the same or similar specialty, who share the same overhead and staff and practice medicine together.

Question 9

Health Maintenance Organization (HMO)

Answer 9

A type of managed care company that serves participating patients by offering services at a fixed rate within the group of participating providers and facilities. A fixed fee schedule is negotiated with the providers as well.

Question 10

Incident to billing

Answer 10

A method of billing outpatient services provided by a nonphysician provider when working under the direct supervision of a physician.

Question 11

Indemnity plans

Answer 11

Fee-for-service plans that allow the patient to direct his or her healthcare. Typically require the patient to pay deductible and a percentage (cost-share) of the allowed charge. Allows both in-network and out-of-network coverage.

Question 12

Liability

Answer 12

Obligations under law arising from civil actions or torts.

Question 13

Limited Liability Company (LLC)

Answer 13

A legally structured company in which the members of the company cannot be held personally liable for the debts or actions of the company or another party in the company.

Question 14

Managed Care Organization (MCO)

Answer 14

Provides healthcare plans that balance healthcare delivery while controlling costs by limiting the providers who can be seen by the patient and discounting payments to those providers.

Question 15

Medicaid

Answer 15

Federal program administered by each individual state that provides healthcare coverage for indigent and/or medically needy patients.

Question 16

Medicare

Answer 16

Federal program that provides medical insurance coverage to members older than age 65 or to those who are deemed permanently disabled.

Question 17

Nonphysician providers

Answer 17

Also called midlevel providers, providers who are educated and skilled to perform medical services and procedures similar to those of physicians.

Question 18

Point of Service Plan (POS)

Answer 18

Insurance plan that combines some elements of HMO and PPO plans, and allows members to choose a primary care provider who will directly refer to in-network providers when needed.

Question 19

Preferred Provider Organization (PPO)

Answer 19

A type of managed care organization that allow members to see any in-network provider without first obtaining a referral from the patient’s primary care provider.

Question 20

Primary care physician (PCP)

Answer 20

A designated provider who oversees the care and manages the healthcare services for an individual.

Question 21

Professional corporation (PC)

Answer 21

A specific legal company structure that is designed for provision of professional services for their clients, such as lawyers, physicians, or architects.

Question 22

Sole proprietorship

Answer 22

A single professional-owned business in which an individual employs other professionals in the same field. In medical practice, a single physician-owned practice that employs other physicians to work for the practice.

Question 23

Solo practice

Answer 23

Single owner/operator of the company or business. In the medical field, this would represent a single-physician practice.

Question 24

Specialist

Answer 24

In the medical field, an individual who has undergone further specific training in a certain discipline and practices medicine in that discipline, such as dermatology or endocrinology.

Question 25

Third-party payer

Answer 25

Usually refers to an insurance company but can be any other person or organization that is responsible for the medical care coverage of a patient.

Question 26

TRICARE

Answer 26

Government medical program for active duty military and their dependents, as well as coverage for military retirees (after 20 or more years of service).