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capitation A common method of reimbursement used primarily by health maintenance organizations in which the provider or medical facility is paid a fixed, per capita amount for each individual enrolled in the plan, regardless of how many or few services the patient uses. closed panel HMO A multispecialty group practice in which other healthcare providers in the community generally cannot participate. consultation When the primary care provider sends a patient to another provider, usually a specialist, for the purpose of the consulting physician rendering his or her expert opinion regarding the patient's condition. The primary care provider does not relinquish the care of the patient to the consulting provider. copayment The amount of money the patient has to pay out of his or her own pocket. direct contract model enrollees Individuals who are covered under a managed care plan. grievance A written complaint submitted by an individual covered by the plan concerning claims payment, reimbursement, policies, or quality of health services. group model A health maintenance organization that contracts with independent, multispecialty physician groups who provide all healthcare services to its members. Physician groups usually share the same facility, support staff, medical records, and equipment. health maintenance organization (HMO) An organization that provides its members with basic healthcare services for a fixed price and for a given time period. iatrogenic effects A symptom or illness in a patient brought on unintentionally by a physician's activity, manner, or therapy. individual practice association (IPA) Individual healthcare providers who provide all the needed healthcare services for a health maintenance organization. managed care network An interrelated system of people and facilities that communicate with one another and work together as a unit. An approved list of physicians, hospitals, and other providers. network model A health maintenance organization that has multiple provider arrangements, including staff, group, or individual practice association structures. open panel plan A plan in which the providers maintain their own offices and identities and see patients who belong to a health maintenance organization (HMO) as well as patients who do not. Healthcare providers in the community may participate, if they meet certain HMO or individual practice association standards. point of service (POS) preauthorization A cost-containment procedure required by most managed healthcare and indemnity plans before a provider carries out specific procedures or treatments for a patient. The insured must contact the insurer before hospitalization or surgery and receive prior approval for the service. Preauthorization does not guarantee payment. precertification A process whereby the provider (or a member of his or her staff) contacts the patient's managed care plan before inpatient admissions and performance of certain procedures and services to verify the patient's eligibility and coverage for the planned service. predetermination A method used by some insurance companies to find out whether or not a specific medical service or procedure would be covered. Most insurance companies request a written statement from the healthcare provider with the specific CPT codes for the proposed procedures before providing a predetermination of benefits. preferred provider organization (PPO) A group of hospitals and physicians that agree to render particular services to a group of people, generally under contract with a private insurer. These services may be furnished at discounted rates if the members receive their health care from member providers, rather than selecting a provider outside of the network. primary care physician (PCP) In a preferred provider organization plan, a specific provider who oversees the member's total healthcare treatment. referral A request by a healthcare provider for a patient under his or her care to be evaluated or treated, or both, by another provider, usually a specialist. specialist A physician who is trained in a certain area of medicine. staff model A closed panel type of health maintenance organization (HMO) in which a multispecialy group of physicians are contracted to provide healthcare to members of an HMO and are compensated by the contractor via salary and incentive programs. utilization review A method of tracking, reviewing, and giving opinions regarding care provided to patients. Evaluates the necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities to control costs and manage care. Chapter 7 Unraveling the Mysteries of Managed Care