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

In certain managed care plans there is an incentive for the gatekeeper to limit patient referrals to specialists.

In times past, physicians in private practice billed indemnity insurance plans and professional services were reimbursed on a fee-for-service basis.

When an HMO is paid a fixed amount for each patient served without considering the actual number or nature of services provided to each person, this is known as

In a staff model HMO, physicians are hired directly by the health plan that pays their salary.

Medicare-eligible patients are not involved with HMOs or prepaid health plans.

If a primary care physician sends a patient to a specialist for consultation and the specialist is not in the managed care plan, the specialist may bill the primary care physician for payment.

When a physician sees a patient more than is medically necessary, it is called

What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care?

When a capitated patient's services go over a certain amount and the physician can begin asking the patient to pay (fee-for-service), this arrangement is provided in a ___________________ section of the managed care contract or agreement.

America's oldest privately owned, prepaid medical group is the

The abbreviation MCO stands for ______________________________.

What is the correct procedure to collect a copayment on a managed care plan?

What plan allows members of the Kaiser Permanente Medical Care Program to seek medical help from non-Kaiser physicians?

The process called ____________________ is an evaluation of the quality and efficiency of services rendered by a practicing physician or physicians within the specialty group.

Managed care plans allow laboratory tests to be performed at any facility the patient chooses.

How are physicians who work for a prepaid group practice model paid?

The difference between an IPA and a PPG is that member physicians may not own an IPA, whereas a PPG is physician owned.

UR is the abbreviation for ____________________, which is necessary to control costs in the health care setting.

A copayment in a managed care plan is usually a fixed dollar amount (predetermined fee).

Beginning in ______________, the passing of federal legislation in 2010 requires almost everyone to be insured or they will pay a fine.