Home | About Us | Network | Members | Compliance | Population Health Glossary of Terms Name Expanded Name Definition Commercial HMO HMOs sell medical insurance to commercial businesses or employer groups. Employer must sign a contract with the HMO which stipulates the standard benefits and options selected for group's employees and premium payable. Group Model HMO HMOs contract with multi-specialty medical groups of which the physicians are employees, partners or shareholders. HMO Health Maintenance Organization Hybrid health care organizations that combine aspects of insurers with providers. Better able to control costs than can insurance companies and make health care more affordable. Financial risk shared between HMO and their contracted providers through various arrangements (e.g., capitation, per diem rates, fee schedules, case rates, risk pools, discounted FFS payments, outliers) IPA Independent Practice Associations An association of independent physicians, or other organization that contracts with independent physicians, that provides services to managed care organizations IPA model HMO HMOs contract with an association of private practice physicians; care is provided in private offices of IPA's participating physicians Knox-Keene The Knox-Keene Health Care Service Plan Act of 1975 and accompanying laws regulate managed care plans Network model HMO HMOs contract with several medical groups or IPAs Outliers Clause which changes the bais of reimbursement back to discounted charges under certain conditions. Establishes a maximum dollar limit per case for which per diem rates apply. If limit is exceeded, payment reverts to discounted charges. PCP Primary Care Physician HMO members required to choose a PCP to serve as their personal doctor. PCPs coordinate services furnished by various providers in complex cases and serve as gatekeepers, limiting access to specialist and hospital services. PPO Preffered Provider Organization Hybrid of HMO and indemnity insurance in which services are completely paid for Staff Model HMO Employs physicians and other medical staff to provide care to members in HMO-owned clinics/hospitals/pharmacies and other care facilities BFMC CCPN DOHC HDMG HVVMG LMG RMG SMG ADOC Contact Us Glossary Sitemap Privacy Careers © Heritage Provider Network, Inc.