key terms Flashcards
Preferred provider organization (PPO)
Managed care organization structured as a network of healthcare providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge.
Premium
: Money the insured pays to a health plan for a healthcare policy
Preventive medical services
Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests.
Primary care physician (PCP)
A physician in a health maintenance organization who directs all aspects of a patient’s care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper.
Referral
Transfer of patient care from one physician to another.
Revenue cycle
All administrative and clinical functions that help capture and collect patients’ payments for medical purposes.
Schedule of benefits
Summarizes the payments that may be made for medically necessary medical services.
Self-funded (self-insured) health plan:
An organization that assumes the risks of paying for health insurance directly and sets up a fund from which to pay.
Third-party payer:
Private or government organization that insures or pays for healthcare on the behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party.
Accept assignment
A participating physician’s agreement to accept the allowed charge as payment in full.
