Insurance Plans
are plans that are marketed by a private health insurance company instead of government programs.
These companies are used to generate a profit for shareholders, a few operate as non-profit organizations
Each company must meet the requirements for their state
Generally offered through employers
What do managed care plans use PCPs for?
control patient access to specialists.
What is a network HMO model?
two or more group practices are contracted to provide services. Network physicians are paid using a capitation method, which means the physicians are paid a fixed per capita amount for each patient over a stated period.
What is utilization review?
set of techniques used to manage health care costs. Reviews on a case-by-case basis. If a procedure is denied, the patient must be notified.
What is a provider sponsored health plan?
a large provider network or hospital system assumes 100% of the financial risk for insuring teh patient population
What are the basics of Blue cross/Blue shield plans?
Originally founded as a non-profit organization
Provides some form of health insurance in each state
One of the oldest health care insurance companies
The blue cross plan was created to cover hospital expenses
The blue shield plan was created to cover physician services
What are managed care systems?
Physicians, hospitals, and specialists are contracted with MCOs to provide services at the lowest possible cost.
What is a direct contract model?
contracts directly with private physician practices to provide services
What is churning?
when a physician sees a patient more than medically necessary.
What is contact capitation?
based on the concept of paying health care organizations for actual patient visits or "contacts."
What is a fee-for-service plan?
can also be referred to as traditional insurance plans or indemnity plans
Insured pays fixed monthly premium and must meet the deductible before the insurance will pay a percentage of the costs
What is a staff model?
a plan in which the physicians are employed by the HMO. The physicians are paid a salary and may receive bonuses.
What is a point of service plan?
combination of an HMO and PPO with unique features. PCP handles specialty care and referrals. Different benefit levels, and the individual can see a participating or non-participating provider. There are higher deductibles for out of network providers.
What is turfing?
sickest high-cost patients are transferred to other physicians so that the provider appears to be a low utilizer.
What is case-rate pricing?
specialist contracts with the managed care plan for an entire episode of care.
What is managed care?
refers to a group of techniques intended to reduce the cost of providing health care while improving the access to care and the quality of care.
What is a group practice model?
physicians are employed by a group practice. These physicians will be multi-specialty providers that can offer all services to members.
What is a triple option health plan?
allows members to select from three choices, HMOs, PPOs, or indemnity insurance.
What is buffing?
term for making this practice look justifiable to the plan.
What is stop-loss limit?
if the patient's services are more than a certain amount, the physician can begin asking the patient to pay.
What was the purpose of the HMO act of 1973?
Created to do away with the FFS
Gave the federal government authority to assist by providing grants, loans, and requires most employers to offer an HMO to their employees as an alternative
Benefits are basic or supplemental
HMO is a medical insurance that provides coverage of health services for a prepaid, fixed annual fee. Insurers must get services through their specific network.
What is an independent practice association?
contracts with an association of physicians to provide services to their members. Allows physicians to remain individual practitioners. They are allowed to treat non-HMO and HMO patients. Paid on a FFS basis.
What is an exclusive provider organization?
mixture of a PPO and HMO plan. Employers agree not to contract with any other plan. A network of providers must be used.
What are carve out plans?
refer to health insurance contracts that exclude specific diseases or injuries from coverage.
What is value?
based reimbursment programs reward health care providers with incentive payments for the quality of care they provide