Exam 11: The Blue Plans, Private Insurance, and Managed Care Plans

When a managed care plan requires the primary care physician to seek approval before referring a patient to a specialist, it is called obtaining ____________________.

A significant contribution to HMO development was the

Benefits under the HMO Act fall under two categories: ____________________ health services and supplemental health services.

The law states that an employer employing ____________________ or more persons may offer the services of an HMO clinic as an alternative health treatment plan for employees.

Managed care plans never require a CMS-1500 claim form to be completed and submitted.

A program that offers a combination of HMO-style cost management and PPO-style freedom of choice is a/an

Kaiser Permanente's medical plan is a closed panel program, which means

How does an HMO receive payment for the services its physicians provide?

Exclusive provider organizations (EPOs) are regulated by the federal government.

Practitioners in an HMO program may come under peer review by a professional group called a

In an independent practice association (IPA), physicians are

A physician-owned business that has the flexibility to deal with all forms of contract medicine and also offers its own plans is a/an

An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an

In a point-of-service (POS) program, members may choose to use a nonprogram provider at any time.

The Health Maintenance Organization Act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance.

The term turfing means to transfer the sickest high-cost patients to other physicians so that the provider appears as a low utilizer.

Usually, there are no deductibles for managed care plans.

Referral of a patient recommended by one specialist to another specialist is known as

Ross-Loos Medical Group, America's oldest privately owned prepaid medical group, started in Texas.

A primary care physician who controls patient access to specialists is called a/an ____________________.