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question		réponse
staff model HMO commencer à apprendre		Physicians are employees of the HMO and paid a salary
Network model commencer à apprendre		the HMO contracts with at least two groups medical practices described as in network 2
independent practice Association commencer à apprendre		Marcus the health plan Physicians contract with the IPA to treat members of HMO
preferred provider organization PPO commencer à apprendre		a delivery Network that manages and negotiate contracts on behalf of the providers
Health maintenance organizations HMO commencer à apprendre		prepaid health plan
actuary commencer à apprendre		a professional who calculates insurance and annuity risks premiums and dividends
exclusive provider organizations EPO commencer à apprendre		delivery Network inwhich patients must use the services of those provided
copay commencer à apprendre		the out-of-pocket expense you pay the doctor
deductible commencer à apprendre		the amount of money the insurer paid before the insurance company will pay
subscriber commencer à apprendre		Blue Cross Blue Shield known as subscribers rather than policyholders
premium commencer à apprendre		the price paid by the insured for insurance coverage
capitation commencer à apprendre		payment method under which each patient is entitled to receive a set dollar amount of services in each time period
Usual fee commencer à apprendre		determined by whether a provider normally charges for that service
customary fee commencer à apprendre		based on fee charged buy similar providers within geographic area
reasonable fee commencer à apprendre		any special circumstance of this accident
cobra. consolidated Omnibus budget reconciliation Act commencer à apprendre		provides that the employee may continue to be insured through employer plan even after being fired. employee picks up total cost
ERISA. Employee Retirement income Security Act commencer à apprendre		Federal legislation the mandates how employer funded benefit plans must be in administered
coordination of benefits commencer à apprendre		if a service is covered under more than one policy then the insurance companies determine who pays
third-party payer commencer à apprendre		insurance company, government, and Managed Care Organization
Prepaid Plan commencer à apprendre		all types of health plans in which fixed payments are made before services are rendered
pre-authorization commencer à apprendre		Insurance requires that certain procedures be authorized by the insurer before they are performed. failure will result in denial of claim
gatekeeping commencer à apprendre		process of restricting access to services
what is the uninsured statistic commencer à apprendre		45.7 million people or 17% without insurance
Indemnity insurance commencer à apprendre		one-party is exempt from incurred liabilities by the other party
self-insured commencer à apprendre		employer pays for Employees Healthcare
third-party admin commencer à apprendre		companies that manages the paperwork for an employer who establishes a self insured plan
Managed Care commencer à apprendre		describes the combination of payment for Healthcare and delivery of services into one system
what did Blue Cross Blue Shield originally cover commencer à apprendre		they prepaid Baylor University 2 hospitalized for 21 days. a group of teachers
what does a self-insuring employer do commencer à apprendre		the employer pays for Employees Healthcare
what percentage of Americans are covered by some type of insurance commencer à apprendre		78%

Chapter 3

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