Charting Your Course : Seminar I - Taking Your Bearings : Managed Care Words

Appeal-A second level of review by a managed care company of a patient's complaint in an initial review.
Capitation-The primary care doctor is pain a fixed fee for each member of the insurance plan selecting that doctor as a primary care provider. The fee is paid irrespective of services actually rendered. It is important to know whether you are in a capitated health insurance arrangement with your primary care doctor. In capitation, the doctor must absorb the costs that exceed the capitation amount. If you are in a capitation health plan, ask your doctor if this will have any impact on the type of care he or she can provide. Will it affect the number or type of diagnostic exams ordered? Will is affect any decision about hospitalization?
Co-payment -A cost-sharing requirement in which the patient pays a certain charge for health services, such as $8 for each office visit.
Deductible -The amount of money that a patient must pay each year before the insurance plan makes payment for eligible benefits.
Exclusive Provider Organization (EPO) -The insured is limited to selecting providers from a limited list. Going to a provider not on this exclusive list may cost the insured from 20% to 100% of the cost incurred.
Fee for Service-This is the traditional method of insurance where the providers (doctors and hospitals) are paid after they provide services.
Gatekeeper-The role played by the primary care doctor in managed care plans to control how patients use other services in the plan.
Health Care Alliances (HCAs) -Prepaid plans for providing treatment of acute and chronic conditions; also promotes preventive care and wellness programs. HCAs may require all care be provided by a limited group of providers. The survivor generally must pay the cost of services secured outside the HCA without prior approval.
Health Maintenance Organizations (HMOs) -Prepaid plans for providing treatment of acute and chronic conditions; also promotes preventive care and wellness programs. HMOs may require all care be provided by a limited group of providers. The survivor generally must pay the cost of services secured outside the HMO without prior approval.
HMO-Staff Model -Utilizes single hospital and employs salaried doctors who do not work outside the HMO.
HMO-Independent Practitioner Associations (IPAs) -Utilizes large numbers of hospitals, doctors.
Integrated Delivery System-Hospitals, doctors and providers work together to provide most appropriate, cost effective, quality care.
Medicaid Managed Care-States obtain a waiver under the Social Security Act to enroll Medicaid recipients in a managed care plan. The states administer these plans or contact with private insurers to manage the plan. The quality of Medicaid managed care plans varies from state to state.
Network of healthcare providers-Doctors, hospitals, lab and other healthcare workers who contact with managed care companies to provide care of the customer (patient).
Out-of-pocket-The portion of payment that the patient is required to pay. This includes co-payment, monthly premium, and deductibles.
Point of Service-Hybrid benefit system between PPO and HMO that allow patients to opt to self-refer to non-network provider for lesser reimbursement benefit. Amount or patient co-payment may be 20% to 100%. Patients should check the terms of their policy to determine the specific amount of reimbursement for non-network providers.
Preferred Provider Organization (PPO) -A network based indemnity plan that lowers participants deductibles and co-payments if they choose to utilize contracted preferred providers. Generally there is a system of utilization review by a third party.
Primary Care Physician/Provider (PCP) -A board-certified or board-eligible family practice, general practice, internist, pediatrician or gynecologist chosen by each insured at point of entry into a managed care delivery system. All services provided are done so by, or with the approval of, the PCP. Also referred to as the "gatekeeper" to the managed care delivery system.
Prior review (or prior authorization) -Primary care doctor must obtain authorization for emergency care, hospital admissions, surgical procedures, referral to specialists, and certain medical tests and procedures. In some cases, a second opinion is required before surgery will be authorizes.
Retrospective review-Utilization review to determine appropriateness of care after the care has been provided. Reimbursement may be denied following a retrospective review. The decision of the insurer may be appealed by the doctor, the insured, or by other care providers.
Traditional Indemnity Plan-Insurance plan that pays doctors and providers retrospectively for what they bill; there is no restriction in choice of provider. Also called fee for service.

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This content is derived from the "Charting Your Course Seminars: A Whole Person Approach To Living With Cancer", provided by Norris Cotton Cancer Center.