Chapter 8 Question
Utilization review organization
A company hired by a payer to evaluate the appropriateness and medical necessity of hospital-based healthcare services
Consumer driven health plans have what effect on a practice's cash flow?
A high-deductible payment from the patient takes longer to collect than does a copayment.
Which laws govern the portability of health insurance?
COBRA and HIPAA
Providers who participate in a PPO are paid
Discounted fee-for-service
Self-funded health plans are regulated by
ERISA
Under a capitation HMO plan, the physician practice receives
a monthly enrollment list
Repricer
a vendor that processes a payer's out of network claims
BlueCross BlueShield Association member plans offer
all major types of health plans
Subcapitation
arrangement by which a capitated provider prepays an ancillary provider
Stop-loss provision
contractual guarantee against a participating provider's financial loss due to an unusually large demand for high-cost services
Monthly enrollment list
document of eligible members of a capitated plan registered with a particular PCP for a monthly period
Rider
document that modifies an insurance contract.
The largest employer-sponsored health program in the United States is
federal employees health benefits program
Host plan
in a BlueCard program, the provider's local BCBS plan
High Deductible Health Plan
insurance plan, usually a PPO, that requires a large amount to be paid before benefits begin; part of a consumer driven health plan
If employer-sponsored health plans, employees may choose their plan during the
open enrollment period
Carve out
part of a standard health plan that is changed under a negotiated employer-sponsored plan
What document is researched to uncover rules for private payer's definitions of insurance related terms?
participation contract
Precertification
payer preauthorization for elective hospital-based services and outpatient surgeries
Emergency surgery usually requires
precertification (preauthorization) within a specified time after the procedure
Plan summary grid
quick-reference table for health plans
Elective surgery
surgical procedure that can be scheduled in advance
Metal plans
term for the new designs of health plans created by the ACA