Medical Groups
A physician-owned business that has the flexibility to deal with all forms of contract medicine and also offers its own plans is a/an _____?
PPG
Preferred provider group
What is the correct procedure to collect a copayment on a managed care plan?
Collect the copayment when the patient arrives for the office visit.
________ means to transfer the sickest high-cost patients to other physicians so that the provider appears as a low utilizer.
Turfing
Usually, there are no deductibles for managed care plans.
True
Referral of a patient recommended by one specialist to another specialist is known as
Tertiary care
A program that offers a combination of HMO-style cost management and PPO-style freedom of choice is a/an ___?
point-of-service (POS) plan.
What is a deductible?
The amount you pay for covered health care services before your insurance plan starts to pay.
Define Churning
When a physician sees a patient more than is medically necessary
Managed care plans never require a CMS-1500 claim form to be completed and submitted.
True
What plan allows members of the Kaiser Permanente Medical Care Program to seek medical help from non-Kaiser physicians?
POS Point of service
America's oldest privately owned, prepaid medical group is the ___?
Ross-Loos Medical Group
How are physicians who work for a prepaid group practice model paid?
Salary paid by independent group
Define capitation ?
is a system of health insurance payments in which health professionals are paid fixed amounts per month based on the number of insured people they have as patients.
Dr's paid fixed amounts per month based on # of insured pt's
Medicare-eligible patients are not involved with HMOs or prepaid health plans.
False
What is point of service ?
is a managed-care health insurance plan that provides different benefits for using in-network or out-of-network providers.
How are physicians who work for a prepaid group practice model paid?
Salary paid by independent group
why is it important to maintain an organized Accounts receivable file?
To make sure payments are received on time and in full, to document who owes and what amount they owe.
good record keeping keeps the office running efficiently
A primary care physician who controls patient access to specialists is called a/an ____________________.
Gatekeeper
In a staff model HMO, physicians are hired directly by the health plan that pays their salary.
true
The abbreviation MCO stands for
managed care organization
Kaiser Permanente's medical plan is a closed panel program, which means ?
It limits the patient's choice of personal physicians
define coinsurance
a cost-sharing requirement under a health insurance policy in which the insured will assume a percentage of the costs for covered services.
UR is the abbreviation for ____________________, which is necessary to control costs in the health care setting.
Utilization review
The Health Maintenance Organization Act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance.
True
Explain "stop-loss" that might appear in a managed care contract
If the patient service exceeds a certain amount, the physician may ask the patient to pay