Chapter 11 Test
The Blue Plans, Private Insurance and Manage Care plans
Terms
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- Case Rate Pricing
- the specialist contracts with the managed care plan for an entire episode of care
- Situations that may affect UR
- Churning, turfing, buffing
- Freedom to choose
- What unique feature does a PPO plan offer to its members?
- Point-of-Service Plans
- Combines elements of an HMO and a PPO while offering some unique features
- Independent Practice Association
- As a part of this association, the physicians are not employees and are not paid salaries:
- Health Maintenance Organization Act of 1973
- Significant contribution to HMO development
- EPOs are regulated under insurance statutes
- how are EPO's regulations different from HMO's regulations?
- HMO Models
- Prepaid group practice model, staff model, network model, direct contract model
- Stop-Loss Limit
- if the patient's service are more than a certain amount, the physician can begin asking the pt to pay (fee-for-service)
- Triple-Option Health Plan
- Allow members to select from three choices: HMO, PPO, Indemnity insurance
- Capitiation
- HMO's are paid a fixed amount for the numbers of patients enrolled w/o considering the actual number of services provided to each patient this is known as:
- PPGs
- A physician owned business entity that has the flexibility to deal with all forms of contract medicine and still offer its own packages to business groups, unions, and the general public
- Kaiser Permanente's closed panel program
- Limits the patients choice of personal physicians to those practicing in one of the 12 regions
- Turfing
- is to transfer the sickest, high-cost patients to other physicians, illegal
- Contact Capitation
- based on the concept of paying physicians for actual patient visits or contacts
- Network Facilities
- Where are laboratory and radiology tests of managed care plans performed and are commonly referred to as?
- Carve outs
- Medical services not included in the health insurance contract benefit are known as:
- Buffing
- A physicians justifying the transference of sick, high-cost patients to other physicians in a managed care plan
- Ross Loos Medical Group 1929
- What organization was America's oldest privately owned prepaid medical group and when was it founded? Now known as CIGNA Healthplans of California
- Utilization Review
- UR is a management system used to control cost in a managed care setting, Reviews individual cases to determine medical necessity for medical tests and procedures
- Payment Mechanisms
- Contact Capitation, Case Rate Pricing, Stop-Loss Limit
- Gatekeeper or primary care physician
- A physician in charge of patients access to specialist and diagnostic testing services is called?
- Formal Referral
- an authorization request is required by the MCO contract to determine medical necessity. This may be obtained via telephone or a completed authorization form mailed, faxed or email.
- Quality Improvment Organization
- Contracts with CMS to review medical necessity, reasonableness, appropraiteness, and completeness and adequacy of inpatient hospital care
- EPO
- Exclusive Provider Organization
- Prepaid Health Plan
- HMO's are what kind of health plan?
- ID card
- Patients name, Member number, Group number, Primary Care Physician's name
- Foundations for Medical Care
- An orgainzation of doctors sponsored by state or local medical association that is concerned with development and delivery of medical services and the cost of health care
- First FMC
- was founded in Stockton, Ca 1954
- PPOs
- Contracts with group of providers to deliver care to members