A Doctor Who Has A Contract With Your Health Plan?

Preferred Provider

A provider who has a contract with your health insurer or plan to provide services to you at a discount.

What is it called when an insurance company contracts with a group of doctors?

Individual insurance. Health insurance purchased by an individual, not as part of a group plan.

In-network

. A group of doctors, hospitals and other healthcare providers preferred and contracted with your insurance company. You will receive maximum benefits if you receive care from in-network providers.

What does it mean to contract with a managed care organization?

Managed care plans are a type of health insurance.

They have contracts with health care providers and medical facilities to provide care for members at reduced costs

. These providers make up the plan's network. How much of your care the plan will pay for depends on the network's rules.

What is a participating provider?

Participating Provider —

a healthcare provider that has agreed to contract with an insurance company or managed care plan to provide eligible services to individuals covered by its plan

. This provider must agree to accept the insurance company or plan agreed payment schedule as payment in full less any co-payment.

What is POS in medical terms?

A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.

What is an HMO quizlet?

Health Maintenance Organization (HMO)

An organization that provides its members with basic healthcare services for a fixed price and for a given time period

.

Under what system do a group of doctors and hospitals in a designated area contract with an insurer?

Under a

Preferred Provider Organization (PPO)

, a group of doctors and hospitals in a designated area contract with an insurer to provide services at a prearranged cost to the insured.

What does subscriber mean for health insurance?

The subscriber is

the person subscribing to or carrying the insurance plan for the patient case

. How is the patient related to the subscriber? For example, if the subscriber is the mother of the patient, then the Patient Relationship to Subscriber is Child.

What is the difference between policyholder and subscriber?

Related Definitions

Policyholder or Subscriber means the primary insured named in an Individual Insurance Contract

. Policyholder or Subscriber means the primary insured (Plan Participant) named in an Individual Insurance Contract.

Who Receives Managed health Care Plan services?

Do I Qualify?

Most people 65 and older

. Some younger people with disabilities. People with End-Stage Renal Disease (kidney failure requiring dialysis or a transplant).

What individuals are involved in managed care contracts?

• Individual physicians.
• Private practices.
• Hospitals.

Why should a medical office specialist be familiar with terms used in managed care contracts?

Medical office specialists should be familiar with terms used in managed care contracts because

they need to be able to review contracts and discuss issues with patients and carriers

. A new patient, Lucy Vrabel, has just given you her insurance information.

What does the designation of participating physician mean?

Participating Physician means

a Physician who, at the time of providing or authorizing services to a Member, is under contract to provide Professional Services to Members

.

Do all doctors have to accept Medicare?

Not all doctors accept Medicare

– here's why that matters.

According to the Centers for Medicare and Medicaid Services (CMS) most doctors will accept Medicare. This means that they will: Accept Medicare's guidelines as the full payment for bills. Submit claims to Medicare, so you only have to pay your share of the bill.

What is a preferred provider agreement?

Preferred Provider Agreement means

an agreement between the PPO and a Provider that contains the rates and reimbursement methods for services and supplies provided by such Provider

.

What does HMO mean in healthcare?

A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage.

What is a EPO plan?

A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan's network (except in an emergency)

.

What does PPO stand for in healthcare?

PPO stands for

preferred provider organization

. Just like an HMO, or health maintenance organization, a PPO plan offers a network of healthcare providers you can use for your medical care.

Which is a plan characteristic for patients with an HMO?

In a very general sense, HMOs offer

predictable cost-sharing and administrative simplicity

for patients. These features come with fairly restrictive rules about which providers patients may see.

What three characteristics are required for an organization to qualify as an HMO?

• An organized system for providing health care or otherwise assuring health care delivery in a geographic area.
• An agreed-upon set of basic and supplemental health maintenance and treatment services.
• A voluntarily enrolled group of people.

What is the main goal of HMO?

The purpose of a Health Maintenance Organization is

to focus on overall patient wellness and preventive healthcare while keeping costs low for its members by only covering in-network physicians and facilities

.

What is a prepaid group?

Prepaid group practices (PGPs) are

complex organizations that directly combine prepayment for health care with a comprehensive health care delivery system

. As such, Schoenbaum says, their ability to manage physician staffing efficiently must be placed in context with the cost and quality of their care.

Which of the following is an example of a managed care plan?

Managed care plans, such as

HMOs, PPOs, and POS plans

, offer comprehensive medical services to their members. They also apply financial incentives that encourage providers to keep both the quantity and cost of services in check and motivate members to select cost-effective providers.

What type of insurance covers the medical expenses of individuals and groups?

Commercial health insurance

covers the medical expenses of individuals and groups. Group health insurance can be available through labor unions, rural.

What is the difference between a subscriber and a member?

At the simplest point,

a subscriber is subscribing to a service or product and a member is part of a community

. When it comes to building a membership website, subscribers can become members and members can subscribe to benefits – which is probably why there is some confusion to member vs. subscriber.

What is the difference between guarantor and subscriber?

A Guarantor (or responsible party) is the person held accountable for the patient's bill. The guarantor is always the patient, unless the patient is a minor or an incapacitated adult.

The guarantor is not the insurance subscriber, the husband, or the head of household

.

When the insured person pays an annual cost for healthcare?