04: Cost Containment Flashcards
The potential to lose money, earn less, or spend more time without additional payment on a reimbursement transaction is known as…
Risk
This reimbursement type is characterized by the party paying the bill (e.g., insurance company, government agency, or patient) being the one who absorbs all the risk.
Fee for service (FFS)
This reimbursement type is characterized by a portion of the risk being shared between payer and provider.
Bundle services
Which unit of payment for services is characterized by “payment per visit or procedure” and has the incentive to provide more services to bring greater revenue?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
A
Which unit of payment for services is characterized by “one payment made for each patient per month (or year)”?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
D
Which unit of payment for services is characterized by “physician is paid one lump sum for all services delivered during an episode of illness” and has the incentive to limit the number of visits?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
B
Which unit of payment for services is characterized by “payment per visit/procedure” and has the incentive to provide more services to bring greater revenue for the visit/procedure?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
C
Which unit of payment for services is characterized by “facility is paid for all services delivered to a patient in 1 day”?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
C
Which unit of payment for services is characterized by “includes a global budget payment of hospitals and salaried payment of physician (lump sum) per ‘X’ period” and has the incentive to provide more services to bring greater revenue?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
E
The usual, customary, and reasonable system (UCR) allowed physicians what?
Flexibility in their fees
What did the resource-based relative-value scale (RBRVS) do?
Created a fee schedule by “area” (like in a PPO)
Roy sees his physician for a recent onset of diabetes. The physician spent 20 minutes on the exam ($92), finger stick blood glucose ($8), urinalysis ($15), and ECG ($70). Because Roy has no insurance, the physician reduced the bill from $185 to $90.
This demonstrates what construct of FFS?
Usual, Customary, and Reasonable system (UCR)
A physician is contracted with Blue Cross to care for its PPO at 70% of his normal fee. Rick, a PPO patient, comes in with a severe headache and weakness in his right arm. The Physician sees him for 20 minutes at a fee of $100. The Physician gets paid $70 from PPO.
This demonstrates what construct of FFS?
Resource-Based Relative-Value Scale (RBRVS)
Dr. Brett removes Larry’s gallbladder and is paid $1300 by Blue Cross. Besides performing the surgery, he sees Larry three times in the hospital and twice in his office for post-operative visits. He cannot bill separately for visits, so $1300 covers everything.
What unit of payment is described here?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
B
Carve-outs and Risk Adjusted are two types of which unit of payment?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
D
