Ch 13 - Healthcare Business and Operations Flashcards
Associate Practice
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.
CHAMPVA
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.
Coinsurance
The percentage of payment that is agreed on by the insured as their portion of any claims; cost-sharing.
Copay
A fixed amount determined by the health insurance policy that is paid for services to offset premiums paid by the insured.
Corporation
A company that is established legally and is managed by a board of directors.
Deductible
An amount of money that is paid by the insured before the insurance company pays for services. Usually a fixed amount paid annually.
Gatekeeper
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.
Group practice
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.
Health Maintenance Organization (HMO)
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.
Incident to billing
A method of billing outpatient services provided by a nonphysician provider when working under the direct supervision of a physician.
Indemnity plans
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.
Liability
Obligations under law arising from civil actions or torts.
Limited Liability Company (LLC)
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.
Managed Care Organization (MCO)
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.
Medicaid
Federal program administered by each individual state that provides healthcare coverage for indigent and/or medically needy patients.
Medicare
Federal program that provides medical insurance coverage to members older than age 65 or to those who are deemed permanently disabled.
Nonphysician providers
Also called midlevel providers, providers who are educated and skilled to perform medical services and procedures similar to those of physicians.
Point of Service Plan (POS)
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.
Preferred Provider Organization (PPO)
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.
Primary care physician (PCP)
A designated provider who oversees the care and manages the healthcare services for an individual.
Professional corporation (PC)
A specific legal company structure that is designed for provision of professional services for their clients, such as lawyers, physicians, or architects.
Sole proprietorship
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.
Solo practice
Single owner/operator of the company or business. In the medical field, this would represent a single-physician practice.
Specialist
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.
Third-party payer
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.
TRICARE
Government medical program for active duty military and their dependents, as well as coverage for military retirees (after 20 or more years of service).
