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| Question | Answer |
|---|---|
| A system of payment used by managed care plans in which physicians and hospitals are paid a fixed per capita amount for each patient enrolled over a stated period of time regardless of the type and number of services provided is called | capitation |
| MCO | managed care organization |
| HMO | health mantenance organization |
| When a prepaid group practice plan limits the patients choice of personal physicians this is termed | closed panel program |
| NCQA | national committee for quality assurance |
| HEDIS ` | health plan employer data information set |
| PCP | primary care physician |
| a physician who controls patient access to specialists and diagnostic teating services is known as a | gatekeeper |
| EPO | exclusive provider organization |
| FMC | foundation for medical care |
| IPA | independent practice association |
| PPO | preferred provider organization |
| PPG | physician provider group |
| POS | point of service plan |
| PSO | provider-sponsored organization |
| QIO | quality improvement organization |
| A program that contracts with cms to review medical necessity, reasonableness, appropriateness, and completeness and adequancy of inpatient hospital care for which additional payment is sought under the outlier provisions of the prospective payment system | quality improvement organization |
| A CMS initiative to strengthen managed care organization efforts to protect and improve the health and satisfaction of medicare and medicaide beneficiaries is called | quality improvement system for managed care |
| QISMC | quality improvement system for managed care |
| This manage system is necessary to control cost in a managed care setting that determins the medical necessity for medical tests and procedures | utilization review |
| UR | utilization review |
| What occurs when a physician sees a patient more than medicaly necessary. | churning |
| What term is used when the sickest, high-cost patients are transferred to other physicians so that the provider appears to be a low utilizer | turfing |
| What term for making this practice look justifiable to the plan. | buffing |
| Medical services not included in the contract are called | carve outs |
| What kind of referral is an authorization request is required by the MCO contract to determine medical necessity | formal referral |
| What kind of referal is an authorazation request form is completed and signed by the physician and handed to the patient | direct referral |
| What kind of referral is when a primary care physician informs the patient and telephones the referring physician that the patient is being referred for an apointment | verbal referral |
| What kind of referral is when the patient refers himself to a specialist | self-referral |
| When services are requested by a specialist from another specialist it is called | tertiary care |
| A specific dollar amount that must be paid by the insured before a medical insurance plan begins covering health care cost is known as | deductible |
| A patients payment of a protion of the cost at the time the service is rendered is known as | copayment |
| When a certain percentage of the monthly capitation payment or a percentage of the allowable charges to physicians is set aside to operate a manage care plan is known as | withhold |
| When a specialist contracts with the manage care plan for an entire episode of care is known as | case rate pricing |
| If the patients services are more than a certain amount, the physician can begin asking the patient to pay is known as | stop-loss limit |
| When a manage care plan retains a percentage of the monthly capitation payment or a percentage of the allowable charges to physicians until the end of the year to cover operating expenses is known as | withhold |
| This is a type of managed health care plan that combines features of HMO and PPOs, and it is offered to large employers who agree not to contract with any other plan is called | exclusive provider organization |
| An organization of physicians sponsored by a state or local medical association concerned with the development and delivery of medical services and the cost of health care is known as | foundation for medical care |
| A type of HMO in which a program administrator contracts with a number of physicians who agree to provide treatment to subscribers in there own office. The physician are not employees of the MCO and are not paid salaries. | independent practice association |
| A type of health benefit program in which enrollees receive the highest level of benefits when they obtain services from a physician or hospital designated by their program as a preferred provider | preferred provider organization |
| A physician owned business that has the flexibility to deal with all forms of contract medicine and still offer its own packeges to business groups, unions, and the gerneral public | physician provider group |
| A manage care plan in which menbers are given a choice as to how to receive services, weather through an HMO, PPO, or fee-for-service plan. The decision is made at the time the service is necessary | point-of-service |
| Those who have voluntarily enrolled in an HMO plan from a specific geographic area, or who are covered by an employer who has paid an established sum per person to be covered by the plan are eligibal for a | managed care plan |
| A type of HMO in which the health plan hires physicians directly and pays them a salary insted of contracting with a medical group | staff model |
| An HMO contracts with two or more group practices to provide health services, which the physicians are paid a capitation amount for the care of each HMO patient in there panel regardless if the patient is seen by the physician in any given month | network HMO |
| A type of managed care health plan contracts directly with private practice physicians in the community rather that intermediary such as a IPA or medical group | direct contract model |
| What designs and sponsors prepaid health programs or sets minimum benefits of coverage. | comprensive type foundation |
| what provides evaluation of the quality and efficiency of services by a panel of physician to the numerous fiscal agents or carriers involved in its area | claims review type of foundation |
Created by:
maryce
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