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