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
