Chapters 1-4 Flashcards
POS
Point of Service:
PPO
Preferred Provider Organization: members can choose their own doctors and facilities.
Subscriber
person who prepays the fee for insurance coverage.
What are the two type of insurance contracts?
Service Benefit Contracts
and
Indemnity Benefit Contracts
Plans that have participating physicians.
Service Benefit Contracts
An insurance contract that covers the actual expenses for providing a service. This type of contract sometimes allows the physician to bill the subscriber for any amount not covered by the insurance company.
Indemnity Benefit Contract
What are the three level of payments for participating physicians?
- Usual, customary and reasonable
- Customary maximum
- Fixed Fee Schedule
The amount a physician would normally charge the majority of patients, the fee most physicians in the geographic area charge, and the amount determined to be appropriate for the service or procedure.
Usual, customary and reasonable
The fee charged by most physicians in the community.
Customary maximum
the maximum fee allowed by the insurance company for a specific medical service or procedure.
Fixed Fee Schedule
EOB
Explanation of Benefits
The prepaid health plan in which individuals receive medical services from participating physicians.
Health Maintenance Organization (HMO)
A health care plan that allows members to choose their own doctors and treatment facilities, but benefit from choosing a participating physician in this plan and also receive less benefits from nonparticipating physicians.
Preferred Provider Organization (PPO)
A health care plan that consists of participating physicians and hospitals who offer discounted healthcare for plan participants. At non participating facilities, the patients benefits are decreased.
Point of Service Plans (POS)
The amount at which the co-payment drops.
threshold limit
A health care plan physicians own to negotiate individual contracts with employers, insurance companies and other entities in order to provide healthcare coverage.
Physician Provider Groups (PPGs)
A bill in 2003 allowing a way for individuals to make yearly contributions to an account toward medical expenses on a tax-free basis.
Health Savings Account (HSA)
p. 4-11 gives other restrictions on who can have an HSA
A plan requiring a deductible of $1,200 for an individual or $2,400 for a family in order to set up a HSA.
High Deductible Health Plan (HDHP)
The approval of the managed care provider for certain procedures.
Preauthorization
Consists of physicians who evaluate the physicians in managed care situations to make sure their patients are receiving proper care.
Peer Review Organization
aka
Professional Review Organizations
This program safeguards against unnecessary and inappropriate medical care.
Utilization Review Program
A participating physicians reimbursement is based on how many patients the physician sees rather than which services the physician performs.
Capitation
The limitation on the number of visits to specialists a patient may make or the number of special treatments, such as physical therapy.
Visitation Limits
A card that contains vital information for each managed care program used by patients of the doctors you work with. Information should include your contact, co-payment info, preauthorization requirements and a list of participating facilities.
Managed Care Quick Reference Card
