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Show health insurance contract specifying which services/procedures are not available as a benefit. Exclusive Provider Organization (EPO) A managed care organization that is organized similarly to PPOs in that physicians do not receive capitated payments, but that only allows patients to choose medical care from network providers. If a patient elects to seek care outside of the network, then he or she will not be reimbursed for the cost of the treatment. Exclusivity Clause A part of a contract that prohibits physicians from contracting with more than one managed care organization (HMO, PPO, IP A, etc.). Experience Rating A process wherein insurance companies evaluate the risk of an individual or group by looking at the applicant's health history and utilization. F Federally Qualified HMOs HMOs that meet certain federally stipulated provisions aimed at protecting consumers, e.g., providing a broad range of basic health services, assuring financial solvency, and monitoring the quality of care. HMOs must apply to the federal government for qualification. The process is administered by the Health Care Financing Administration (HCFA), Department of Health and Human Services (DHHS). Fee Disclosure Physicians and caregivers discussing their charges with patients prior to treatment. Fee-for-service The traditional payment method whereby patients pay doctors, hospitals, and other providers for services rendered and then bill private insurers or the government. Fee Schedule A comprehensive listing of fees used by either a health-care plan or the government to reimburse physicians and/or other providers on a fee-for-service basis. Fiscal Intermediary The agent that has contracted with providers of service to process claims for reimbursement under health-care coverage. In addition to handling financial matters, it may perform other functions such as providing consultative services or serving as a center for communication with providers and making audits of providers' needs. Formulary A list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and cost-effective for patient care. Organizations often develop a formulary under the aegis of a pharmacy and therapeutics committee. In HMOs, physicians are often required to prescribe from the formulary. G Gatekeeper A primary care physician responsible for overseeing and coordinating all aspects of a patient's medical care. In order for a patient to receive a specialty care referral or hospital admission, the gatekeeper must preauthorize the visit, unless there is an emergency. Group Insurance Any insurance policy or health services contract by which groups of employees are covered under a single policy or contract, issued by their employer or other group entity. Group Model HMO An HMO that contracts with a multi-specialty medical group to provide care for HMO members; members are required to receive medical care from a physician within the group unless a referral is made outside the network. H Health Maintenance Organization (HMO) HMOs offer prepaid, comprehensive health coverage for both hospital and physician services. An HMO contracts with health-care providers, and members are required to use participating providers for all health services. Members are enrolled for a specified period of time. Model types include staff, group practice, network and IPA. Health Plan Employer Data and Information Set (HEDIS) A set of performance measures designed to standardize the way health plans report data to employers. HEDIS currently measures five major areas of health plan performance: quality, access and patient satisfaction, 157 |
