Chapter 14

IPA

group of providers and other health care professionals who are under contract to provide services to members of different HMOs

government-sponsored health insurance

health insurance programs that are sponsored by the government and offer coverage for the elderly, disabled, military, and indigent

medically necessary

health services that are necessary to improve the patient's current health condition

preventive care

includes services provider to help prevent certain illnesses or that lead to an early diagnosis

in-network

locations that are contracted in the patients health insurance plan; hospitals, urgent care, medical offices

out-network

many facilities do not reimburse for this type of care

allowable charge

maximum that third-party payers will pay for a procedure or service

elective procedure

medical procedures that are not deemed medical necessary or needed to improve current health

premiums

monthly payments

group model

multispecialty group with or without a PCP; may contract with several IPAs

staff model

one or more providers hired by an HMO

verification of elegibility

process of confirming health insurance coverage for the patients for the medical service on the date of service

beneficiary

recipient of health insurance benefits

HMO

require them to include preventive care, such as routine physical examinations and other services

gatekeeper

the PCP who can approve or deny when the patient seeks additional care via referral to a specialist or further medical tests

subscriber

the person who is the signer on the health insurance policy

participating providers

contracted with the insurance plan and have agreed to accept the contracted fee schedule

cafeteria style

employers can pick and choose the benefits they want for their empolyees

capitation

a contract between the health insurance plan will and the provider for which the health insurance plan will pay an agreed upon monthly fee per patient and the provider agrees to provide medical services on a regular basis

group policy

a privately sponsored health insurance plan purchased by an employer for a group of employees

does medicare and medical have premiums

NO

third-party administrator

TPA, the intermediary and administrator who coordinates patients and providers, as well as process claims, for self-funded plans