Final Exam Flashcards
provision of a health insurance policy that requires the insured individual to pay some portion of his or her medical expenses
cost sharing
type of cost sharing where the insured or covered person pays a flat amount per unit of service or unit of time and the insurer pays the rest
deductible
portion of covered health care cost for which the covered person has a financial responsibility which is usually a fixed percentage
co-insurance
rate that the subscriber pays for specific health services
premium
insurance companies will evaluate the fees charges to determine if they are the usual, customary, and reasonable fees charged in the area where the services are renered
usual, customary, and reasonable (UCR)
patient care - offered by HMO’s and many PPO’s in response to patient demand for direct access to doctors of their choice
point of service (POS)
contractual agreement between providers and an employer or insurance company to deliver health services to a defined patient population at established fees
preferred provider organization (PPO)
health care provider almost exclusively associated with HMO’s who controls access to the network
gatekeeper
offers prepaid, comprehensive health coverage for both physician’s fees and hospital services
health maintenance organization (HMO)
an HMO that contracts with individual physicians or groups of physicians who are in independent practice
HMO-IPA
third party who manages the relationship between a doctor and patient
managed care organization (MCO)
PCP
primary care physician
case where the MCO or insurer has another doctor examine and evaluate your patient and make recommendations for further care
independent medical examination (IME)
PMPM
per member per month
payment plan is a form of prepayment to providers w/ PMPM
capitation
