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Semester 3 PID Exam 4 > 3rd Party Payers > Flashcards

3rd Party Payers Flashcards

1
Q

Charity Care

A

Pro Bono - low income level, no insurance

Financial assistance programs

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2
Q

Self Pay

A

No insurance
Does not qualify for charity/pro bono
May need payment plan
Might get discount if pay cash in full at time of service

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3
Q

Explanation of Benefits

A

Something that says what was done with medical procedure, what the insurance covered, and the write off

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4
Q

Medically Necessary

A

Must be reasonable, evidence based, standard of care

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5
Q

Hospital based service

A

an “outpatient” facility but it is associated with a hospital

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6
Q

NPI - National Provider Identifier

A

All outpatient PTs need an NPI - a medicare number that sticks with you and goes on all of your claims

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7
Q

Write off - contractual

A

Contract with insurance company that says they will pay a certain amount
Say 80 of the 100 so write off is 20

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8
Q

Traditional type of insurance organization

A

Indemnity plans - commercial insurance companies
All organized under state laws
Act as insurers, not providers

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9
Q

Managed Care - type of insurance organization

A

HMO
PPO
POS
EPO

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10
Q

HMO

A

In network

Gatekeeper to control/coordinate care

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11
Q

PPO

A

Contract btw health plan and provider
Encouraged to use specific providers
Can go out of network

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12
Q

POS

A

Hybrid PPO/HMO
Like an open ended HMO
PCP required
Can go out of network

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13
Q

EPO

A

Cross between HMO and PPO

In network care

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14
Q

High deductible health plan (HDHP)

A

Preventative care covered, other expenses must be paid until deductible met
Can be paired with a health savings account (HSA insurance plans) - then you can carry over

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15
Q

Workers Compensation

A

State regulated - employee directs provider or employee choice
Case manager frequently involved
Communication/documentation required for continued approval

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16
Q

Medicare/Medicaid

A

CMS - Centers for medicare and medicaid services

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17
Q

Medicare - parts

A 
A = hospital services
B = outpatient services
C = Medicare advantage plan 
D = outpatient prescriptions (private plans)
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18
Q

Tricare/Champus/VA

A

Health care program for uniformed service members, retirees, and their families
Military tx facilities vs civilian providers

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19
Q

Patient protection and affordable care act - Aims

A

Inc quality and affordability of health insurance
Lower uninsured rate
Contain rising costs

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20
Q

Patient protection and affordable care act - essential health benefits

A

9 essential health benefits

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21
Q

Patient protection and affordable care act - marketplaces

A

Providers qualified health plans (QHP) - 3 types - state based, partnership and federally facilitated

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22
Q

Qualified Health Plans

A

Cover the essential health benefits
Are modeled after states benchmark plan
Are subject to federal regulation and state insurance laws

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23
Q

Marketplace tips - Grace period

A

There is a grace period so it is important to check patient status
Adding a clause regarding nonpayment of health insurance premium to patient financial agreement is a good idea

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24
Q

Alternative payment methods

A

Accountable care organizations
Bundled payment models
Patient centered medical home

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25
Q

Accountable care organizations (ACOs)

A

Network of health care providers agree to be accountable for quality, cost and overall care of medicare beneficiaries

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26
Q

ACOs - meet quality standards in four key areas

A

Patient/caregiver experiences
Care coordination/patient safety
Preventative health
At risk population/frail elderly health

27
Q

ACOs and PT

A

PTs can participate in an ACO but cannot create one

28
Q

Bundled payment models

A

Bundled payment paid related to a treatment or conditions
Used to encourage coordination among providers and promote efficient care
Hospitals, physicians, and post acute care providers

29
Q

Comprehensive Care for Joint Replacement - CJR

A

TKA, THA

Being tested for the next 5 years

30
Q

Acute Care Episode - ACE

A

28 cardiac and 9 ortho inpatient surgical services and procedures jointly accountable for patient’s care

31
Q

Patient Centered Medical Homes (PCMH)

A

Primary care practices provide and coordinate patients care
Community based health teams support primary care providers
Prevention, care management for patients with chronic conditions
Focus - managing care and directing medical care appropriately

32
Q

Payment methods

A

Retrospective Payment Systems
Prospective Payment Systems
Pay for Performance

33
Q

Retrospective Payment Systems

A

Fee for service/Fee schedule

34
Q

Prospective Payment Systems

A 
DRG
RUG
Per Diem
Case Rate
Capitation
Multiple procedure payment
35
Q

DRG

A

Diagnostic related group

Based on the diagnossi

36
Q

RUG

A

Resource utilization group

Tiered payment depending on how patient presents and the service that may be needed

37
Q

Per diem

A

per visit - set amount per patient per day

38
Q

Case Rate

A

Per episode of care

39
Q

Capitation

A

You are in agreement with insurance - you will get a set amount no matter what

40
Q

Multiple procedure payment

A

scaled from private insurance

41
Q

Pay for performance is based on

A

quality and outcomes of care

42
Q

How are they covered? Acute Rehab

A

M, A, P

43
Q

How are they covered? Acute Care

A

M, A, B, P

44
Q

How are they covered? Pediatrics

A

M, P

45
Q

How are they covered? SNF

A

M, A, B, P

46
Q

How are they covered? OPT

A

M, B, P

47
Q

How are they covered? Home care

A

M, A, B, P

48
Q

Acute Care Hospital

A

Per Diem - private insurance
FFS - fee for service
Inpatient prospective payment system - DRG
Med part A

49
Q

Acute rehab/Rehab hospital/Inpatient Rehab Facility

A

Per Diem - private insurance
IRF PPS (prospective payment system)
Medicare - newer than DRG but same principle
IRF PAI (need to fill out)
3 hour rule - 3 hrs of therapy 5 days a week

50
Q

SNF

A

Per Diem - private insurance
Case Mix - PPS - Med A
Minimum Data set (MDS)
RUGs - 5 levels (low to ultra high)

51
Q

NH

A

Out of pocket

Medicaid

52
Q

Home Health

A 
PPS for medicare - need to fill out OASIS
Must track minutes of PT
Quality reporting
Med B
Private insurance
53
Q

Outpatient Care

A

Third party payment - FFS, per visit, Case rate, Cpaitation, Med B, Work comp, employer contract/on site
First party payment - self pay

54
Q

Medicare physician fee schedule - Resource based relative value scale

A

Based on difficulty of work, practice expense, and malpractice expense

55
Q

Schools

A

Provide services unter the individuals with disabiliteis in education act and the elementary and secondary education act
Medicaid/childrens health insurance program - fed and state but state administers

56
Q

Upcoding

A

Charging for more complex service

57
Q

Unbundling

A

Billing separately for procedures that are covered by one fee

58
Q

Examples of fraud

A

Upcoding, Unbundling
Charging for services not provided
Double billing
Lack of medical necessity

59
Q

Diagnosis determines reimbursement?

A

DRG

Acute Care

60
Q

Paid for each service that is provided?

A

Outpatient

Fee for service

61
Q

Accept negotiated rate for services for an episode of care?

A

Case rate, ACO, bundle payment

Outpatient or ACO

62
Q

Payment based on patient classification which is tiered according to minutes?

A

RUG

SNF

63
Q

Receive guaranteed monthly lump sum

A

Capitation

Outpatient

Semester 3 PID Exam 4 (3 decks)

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