Ch. 3: Health Insurance Flashcards
(21 cards)
HMO
health maintenance organization
PPO
preferred provider organization
EPO
exclusive provider organization
IDS
integrated delivery system
POS
point of service plan
What are the 4 types of provider reimbursement methods?
- salaried-providers are employed by the MCO
- capitation-receive set fee per month per enrolled member, regardless of # of visits
- fee-for-service-reimbursed for each service
- negotiated or discount fee-same as fee for service, but providers agree to treat members for a reduced fee
MCO
Managed care organizations-this is the five insurance models
what are the 4 general types of HMOs?
- staff model-the HMO operates and staffs the facility where members receive treatment
- IPA-independent practice association-HMO contracts directly with physicians and hospitals
- Group model-contracts with physicians who are organized as a partnership, corp, or association, HMO reimburses the group
- network-contracts with more than one physician group
How does a PPO work?
MCO contracts with a group of providers to offer services to the members. They are paid a maximum allowable fee, which is the most a PPO will pay for a given service, a discounted fee-for-service, or a capitation. Providers accept a reduced payment in return for high patient volume. Members are encouraged by receiving reduced co-payment by using the preferred providers, but it is up to them ultimately on who to use, as the non preferred providers will still be covered, just at a higher co-pay.
How does an EPO work?
similar to a PPO except the members are restricted to use the participating providers for all health care services
How does an IDS work?
it is an MCO that brings together physicians, p groups, hospitals, HMOs, PPOs, insurance companies, management services, and employers to integrate all aspects of patient care into one comprehensive system
How does a POS work
usually, an HMO or PPO, that gives members a choice to receive services from providers outside of the MCO, members can self-refer to a specialist or other provider,
assignment of benefits
permission granted by the insured that allows the insurance company to send payments directly to the provider
preauthorization
determination of whether a specific service or treatment is medically necessary and covered by the insurance policy, required by many insurance companies
precertification
determination of whether a specific treatment or service is covered by the policy
predetermination
determination of the potential dollar amount the insurance company will pay for a specific treatment or service
accept assignment
indicates that a physician or provider is willing to accept the amount the insurance company pays for a service as payment in full
birthday rule
determines the primary payer for a child living with both parents and each parent carries health insurance. the primary payer is the parent whose birth month and date comes earlier in the calendar year
coordination of benefits (COB)
applies when an individual is covered by more than one policy, ensures that the amount paid does need exceed the bill
how does episode-of-care work?
charges a lump sum for all services associated with a particular problem, illness, condition, or procedure. Ex: surgical procedure (preoperative visits, surgery, postoperative)
How does an HMO work?
Requires a PCP (primary care provider) to refer to specialist, have to stay in network, usually only requires a co-pay
