Pioneers in private insurance and had a nonprofit status that made them unique among all private insurance carriers for many years
What is Blue Cross Blue Shield
100
Contracts with CMS to review medical Necessity, reasonableness, appropriateness and completeness and adequacy of inpatient care
What is Quality Improvement Organization
200
Independent Practice Association
What is IPA
200
Medical services not included within the capitation rate
What is carve outs
200
America's oldest privately owned prepaid medical group
What is Ross Loos Medical Group
200
A management system used to control costs in a manged care setting
What is utilization review
300
Exclusive Provider Organization
What is EPO
300
patient pays the physician for each professional service performed
What is Fee for service
300
a prepaid practice group practice that can be sponsored and operated by the government, medical schools, clinics, foundations, hospitals, employers, labor unions, community or consumer groups
What is HMO
300
when physicians sees a patient more than medically necessary
What is Churning
400
Employee Retirement Income Security Act
What is ERISA
400
supportive services other than a routine hospital services provided by the facility
What is Ancillary Services
400
non profit organization that accredits HMO's including traditional staff and group model HMO's network and IPA models
What is National Committee for Quality Assurance( NCQA)
400
when the sickest high cost patients are transferred to other physicians
What is turfing
500
Health Maintenance Organization
What is HMO
500
Services requested by a specialist from another specialist
What is Teritary Care
500
Type of managed care plan that combines features of HMO's and PPO's Employers agree not to contract with any other plan