Question

CHAP 3 KEY TERMS/ABBREVIATIONS

1. CAPITATION
2. COORDINATION OF BENEFITS
3. DAYSHEETS
4. DEDUCTIBLE
5. EXCLUSIVE PROVIDER ORGANIZATION (EPO)
6. HEALTH MAINTENANCE ORGANIZATION
7. INDEPENDENT/INDIVIDUAL PRACTICE ASSOC.
8. MEDICAID/MEDI-CAL
9. MEDICARE
10. POINT OF SERVICE PLAN (POS)
11. PREFERRED PROVIDER ORGANIZATION (PPO)
12. COINSURANCE
13. ELIGIBILITY
14. FINANCIAL ACCOUNTING RECORD
15. PARTICIPATING PROVIDER

ABBREVIATIONS:

1. A/R
2. CHAMPVA
3. COB
4. HMO
5. PPO

Answer 1

Capitation

Is a type of health care payment system in which a doctor/hospital is paid a fixed amount per patient for a prescribed period of time by an insurer or physician association

Co-ordination Of Benefits

This is a process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance policy

Day sheet

A page that list all health care procedures, payments and adjustments for a single day

Deductible

The amount you pay for covered health care services before your insurance plan starts to pay

Exclusive Provider Organisation (EPO)

Is a hybrid health insurance plan in which a primary care provider is not necessary but healthcare provider must be seen within a predetermined network. Out-of network provider is not provided and visit requires pre-authorization

Health Maintenance Organization

A health insurance organisation in which subscribers pay a predetermined fee in return for a range of medical services from physicians and health care workes registered within that organization

Independent/Individual Practice Association

Is a business entity organized and owned by a network of independent physician practices for the purpose of reducing over head or pursuing business ventures such as contracts with employers, accountable care organizations or managed care organizations

Medicaid

Federally assisted and state assissted programs to pay for medical services on behalf of certain groups of low income individual

Medicare

Nation wide health insurance program that provide health insurance to people aged 65 or older. This is also available for individuals with chronic/catastrophic illness such as renal failure requiring hemodialysis, regardless of the age

Point of service plan

It is atype of managed care health insurance plan , provides partial coverage of certain services outside the managed care's network of providers

Preferred Provider Organisation

Is a medical care arrangement in which mediacla facillities are provided to its subscribers at reduced rate. Another characterstic feature is the flexibility of plan- to choose doctors and hospitals ouside the network

Co-insurance

Insured pay a share of payment made against the claim

Eligibility

The date on which patient becomes eligible for insurance benefits

Financial Accounting Record

Is a key source of information and evidence used to prepare/verify/ audit financial statements

Participating Provider

A health care provider that has agreed to contract with an insurance company or managed care plan to provide eligible services to individuals covered by it's plan