Chapter 2 Flashcards
Savings account similar to HSA but limited to qualified individuals based on income.
Health Savings Security Account
A healthcare organization characterized by a payment and care delivery model
that seeks to tie provider reimbursements to quality metrics
and reductions in the total cost of care for an assigned population of patients.
Accountable Care Organizations (ACO)
Fixed payment remitted at regular intervals to
a medical provider by a managed care organization for an
enrolled patient.
Capitation
A service not covered in a health insurance
contract, usually reimbursed according to a different arrangement or rate formula than those services specified under the
contract umbrella.
Carve-out
Third tier insurance
plans that give the members more control over their health
budgets.
Consumer Driven Health Plans (CDHP)
A specified dollar amount the policyholder must
pay to a healthcare provider for each visit or medical service
received. This is typically found on the insurance card.
Copay
A process that is used to evaluate the qualifications and practice history of a physician which includes a
review of a physician’s completed education, training, residency, and licenses.
Credentialing
Managed care plan in
which healthcare expenses are funded by insurance coverage;
the individual selects one of each type of provider to create a
customized insurance premium.
Customized Sub-Capitation (CSC)
A worldwide computerized database of all uniformed service members, their spouses and family members, and others who
are eligible for TRICARE.
DEERS (Defense Enrollment Eligibility Reporting System)
An annual specified dollar amount the policyholder must pay before the insurance carrier begins paying for
services.
Deductible
Insurance that protects an
employer from damages from a lawsuit resulting from an
injury due to the employer’s negligence.
Employers’ Liability Insurance
An organization
that has entered into contracts with medical care providers or
groups of medical care providers to provide healthcare services
to members.
Exclusive Provider Organization (EPO)
A tax-advantaged healthcare account an individual contributes money into that is used
to pay for certain out-of-pocket healthcare costs.
Flexible Spending Account (FSA)
A physician, typically a primary care physician,
like a family practitioner, internist, or pediatrician, who is
responsible for determining a patient’s primary services and
coordinating care so that the patient receives the appropriate
needed services.
Gatekeeper
Health plans that are purchased by
employers for its employees. A portion of the group health plan
premium may be paid by the employer.
Group Health Plans
A medical practice
formed to share economic risk, expenses, and marketing efforts.
Group Practice Without Walls (GPWW)
An organization
that provides comprehensive healthcare to voluntarily enrolled individuals and families in a geographic area by member
physicians with limited referral to outside specialists, and that
is financed by fixed periodic payments determined in advance.
Health Maintenance Organization (HMO)
A savings account used in
conjunction with a high-deductible health insurance policy
that allows users to save money tax-free against medical
expenses.
Health Savings Account (HSA)
An employerfunded plan that reimburses employees for incurred medical
expenses that are not covered by the company’s standard
insurance plan.
Healthcare Reimbursement Account (HRA)
Health plans that are purchased by
individuals for themselves or their families, not as part of a
group plan.
Individual Health Plans
A network of affiliated
facilities and providers working together to offer joint healthcare services to members.
Integrated Delivery Systems (IDS)
A corporate umbrella
for the management of diversified healthcare delivery system.
Integrated Provider Organization (IPO)
An organization that
combines the functions of health insurance, delivery of care,
and administration.
Managed Care Organization (MCO)
A business
providing nonclinical services to providers, like practice
management service, to individual physician practices.
Management Service Organization (MSO)
U.S. government program, financed by federal,
state, and local funds, of hospitalization and medical insurance
for persons of all ages within certain income limits.
Medicaid
U.S. government program of hospitalization insurance and voluntary medical insurance for persons aged 65 and
older and for certain disabled persons under 65.
Medicare
A unique 10-digit identification number required by HIPAA.
National Provider Identifier (NPI)
An organization that
is owned by hospitals and physician groups working cooperatively to develop improved methods of healthcare delivery,
oversee integration of physicians and hospitals into health
delivery networks, assist in voluntary group formation, and
collect, analyze, and disseminate information.
Physician-Hospital Organization (PHO)
A healthcare practitioner, such
as a family practitioner, internist, or pediatrician who is chosen
by an individual to provide continuous medical care, trained
to treat a wide variety of health-related problems.
Primary Care Provider (PCP)
Assesses the physician’s expertise in a specific
practice, like cardiology or surgery, based on documented
competence in the specialty in which privileges are requested.
Privileging
A coverage plan available for military personnel and
their families. It is extended to active and retired personnel.
TRICARE
Allows an insurer to administer three
different healthcare plans so that members may select the
benefit options they want: straight indemnity insurance, an
HMO, or a PPO.
Triple Option Plans
U.S. social insurance
system for industrial and work injuries regulated at a state
level.
Workers’ Compensation Insurance
