Care Delivery and Reimbursement Methods Flashcards
A process by which a single case manager assists clients/support systems with all barriers to health, including those related to physical illnesses or mental health and substance use disorders (mental conditions). Handoffs among case managers and care providers are minimized, and total health outcomes for clients are the responsibility of each individual case manager
Integrated Case Management (ICM)
The process of determining and documenting specific objectives, goals,
and actions designed to meet the client’s needs as identified through the
assessment process; action- oriented and time-specific.
Planning
A holistic, person-centered approach to the management of healthcare and
services of a person with a complex, catastrophic, or life-altering condition or disability with the ultimate goal to promote and maintain the person’s good health, safety, well-being, and quality of life. It applies a consistent methodology for analyzing all of the actual present and potential future needs and their associated expenses dictated by the onset of a catastrophic disability through to the end-of-life expectancy
Life Care Planning
An independent, nonprofit
organization that promotes healthcare quality through accreditation, education, and measurement programs. Its main mission focuses on promoting continuous improvement in the quality and efficiency of healthcare management through processes of accreditation and education. This organization offers a wide range of quality benchmarking services, validates the commitment of healthcare organizations to quality and accountability through accreditation, and ensures that all stakeholders
are represented in establishing meaningful quality measures for the healthcare industry
Utilization Review Accreditation Commission (URAC)
A process of managing occupational and nonoccupational diseases with the aim of returning the disabled employee to a productive work schedule and employment.
Disability Case Management
a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client’s health and human services needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes
Case Management
The goals of case management are improving client’s ________, __________, ___________, and ____________ status.
clinical, functional, emotional, and psychosocial
________ _______ are benefits in the form of payments rather than services. They are also known as fee-for-service benefits. Typically, the healthcare provider bills the patient, and the insurance company reimburses the patient later. The patient is free to choose his provider without restriction, but these policies are more expensive than managed care policies.
Indemnity benefits
A surcharge that high-income people may pay in addition to their Medicare Part B and Part D premiums.
Income Related Monthly Adjustment Amount (IRMAA)
A supplemental cost-sharing arrangement between the member and the insurer in which the member pays a specific charge for a specified service; may be flat or variable amounts per unit of service and may be for such things as physician office visits, prescriptions, or hospital services. The payment is incurred
at the time of service.
A set amount the patient pays each time a specific service is rendered.
Copayment
A type of cost sharing in which the insured person pays or shares part of the medical bill, usually according to a fixed percentage.
Coinsurance
A specific amount of money the insured person must pay for covered expenses before the insurance company begins paying.
Deductible
With this type of reimbursement, each service rendered is priced separately. Providers are paid for each service performed, as opposed to capitation. Fee schedules are an example of this.
Fee-For-Service (FFS)
Bundled payments, case rates, and prospective payment systems are examples of what type of reimbursement model (pays one predetermined amount, no matter the number or cost of services provided)?
Episode-of-care reimbursement model
Rate of reimbursement that packages pricing for a certain category of services.
Typically combines facility and professional practitioner fees for care and services.
Case Rates
A healthcare payment system used by the federal government since 1983 for
reimbursing healthcare providers/agencies for medical care provided to Medicare and Medicaid participants. The payment is fixed and based on the operating costs
of the client’s diagnosis.
Prospective Payment System (PPS)
Both of these payment methodologies make a single comprehensive payment to healthcare providers to cover all services related to a treatment or condition.
Bundled/Case Rate
*bundled is used more often when referring to “bundling” physician and hospital charges or charges to multiple providers in multiple settings
*case rate is used when referring to a flat fee paid to the provider for a client’s treatment based on his diagnosis or presenting problem
A patient classification scheme that provides a means of relating the type of patient a hospital treats to the costs incurred by the hospital. This term demonstrates groups of patients using similar resource consumption and length of stay. It also is known as a statistical system of classifying any inpatient stay into groups for the
purposes of payment. These groups may be primary or secondary; an outlier classification also exists. This is the basis of payment the CMS uses to pay hospitals for Medicare and Medicaid recipients. Also used by a few states for all payers and
by many private health plans (usually non-HMO) for contracting purposes. this predetermined amount is paid regardless of the actual cost of treating the patient. This approach provides a significant incentive for hospitals to decrease costs.
Diagnosis-Related Group (DRG)
A diagnostic tool used to classify patients into distinct groups based on clinical characteristics and expected resource needs. This diagnostic determines the Case Mix Group (CMG) classification.
Inpatient Rehabilitation Facilities Patient Assessment Instrument (IRF-PAI)
Each _______ ___ _____ has a relative weight that determines the base payment rate for inpatient rehabilitation facilities under the Medicare system.
Case Mix Group (CMG)
An encounter-based classification system for outpatient reimbursement, including hospital-based clinics, emergency departments, observation, and ambulatory surgery. Payment rates are based on categories of services that are similar in cost and resource utilization.
Ambulatory Payment Classification (APC) System
Upon admission to home health, the patient is assessed using the ___________________________. This is a prospective nursing assessment instrument that’s score, along with other data on the patient, determines the _________________ the patient will be placed in. The _____________ sets the reimbursement rate.
Outcome and Assessment Information Set (OASIS);
Home Health Resource Group (HHRG);
HHRG
This case-mix classification model relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories. One case-mix variable is the assignment of the principal diagnosis to one of 12 clinical groups to explain the primary reason for home health services. Payment is based on this assignment
Patient-Driven Groupings Model (PDGM)
This case-mix classification model is used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay.
Patient Driven Payment Model (PDPM)
With _____ _________, the HMO and contracted provider each accept partial responsibility for the financial risk and rewards involved in cost-effectively caring for the members enrolled in the plan and assigned to the provider.
risk sharing
With ___________, the provider or provider organization(s) take on more risk because they agree to receive a set payment per-member-per-month (PMPM) for specified medical services from the payer.
capitation
The ______ __________ __ _________ ______ ________ assigns a number or alphanumeric to describe diseases, traumas, and environmental circumstances leading to bodily harm. It is used to report medical diagnoses and procedures on claims as well as to train data for public health surveillance. The ___ _____ is the diagnosis/reason for the encounter with the health system (e.g. chest pain, pre-op evaluation, diabetes).
International Classification of Diseases (ICD) coding system;
ICD code
(Clinical modification) The diagnosis classification system used by all healthcare providers.
ICD-10-CM
(Procedure Coding System) The procedure classification system used for inpatient procedure reporting in hospitals.
ICD-10-PCS
A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by health care providers and usually used for billing purposes (e.g. evaluation and management, venipuncture, ECG).
Current procedural terminology (CPT)
While the ______ code tells the reason for the visit (e.g., chest pain), the ____ code lists the procedure performed (e.g. evaluation and management, venipuncture, ECG).
ICD-10;
CPT
____ combines _____ codes with patient demographics, discharge status, and the presence of complications or comorbidities to classify a hospital admission into a payment category, based on the assumption that similar diagnoses should have similar hospital resource use and length of stay patterns.
DRG;
ICD-10
A set of healthcare providers including primary care physicians, specialists, and hospitals that work together collaboratively and accept collective accountability of the cost and quality of care delivered to a population of patients. These became popular in the Medicare fee-for-service benefit system as a result of the Affordable Care Act and are formed around a variety of existing types of provider organizations such as multispecialty medical groups, physician-hospital organizations (PHI), and organized or integrated delivery systems.
Core components of this model of care:
1. Provider-led - strong base in primary care
2. All providers, across a full continuum of care, are accountable for quality & cost r/t a population of patients
3. Payments are linked to quality improvements that reduce overall costs.
4. Performance is measured.
Accountable Care Organization (ACO)
An approach to providing comprehensive, holistic and integrated primary care for children, youth, and adults. It is a care setting that facilitates partnerships among individual clients, client’s support systems and their primary care providers. Healthcare services
in this setting are facilitated by disease registries, information technology, health information exchange and other means to assure that clients receive the necessary care when and where they need or desire it, in a culturally and linguistically appropriate manner.
Some principles to remember:
1. Personal physician coordinates all care for the patient
2. Personal physician leads a team of providers who are collectively responsible for the ongoing care of the patient
3. Whole person orientation - personal physician provides for pt’s entire healthcare needs or appropriately arranges care
4. Care is coordinated across all elements of the complex healthcare system and provided in a culturally and linguistically appropriate manner
5. enhanced access to care - open scheduling, expanded hours, new options for communication
6. Guided by evidence-based medicine and clinical decision-support tools
7. Physicians accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement
8. Patient participation in decision-making and feedback is sought to ensure expectations are met
9. IT is utilized appropriately to support optimal pt care, performance measurement, pt education, and communication
Patient Centered Medical Home (PCMH)
______ ______ services are available to adults and children who receive benefits from Medicaid and who have at least 2 chronic conditions, such as asthma, diabetes, heart disease, obesity, a mental health condition, or substance abuse disorder; one chronic condition and are at risk for another; or one serious and persistent mental health condition.
*Each patient must have a comprehensive care plan
*Services must be quality-driven, cost-effective, culturally appropriate, person- and family-centered, and evidence-based
*Services must include prevention and health promotion, healthcare, mental health and substance use, and long-term care services, as well as linkages to community supports and resources
*Service delivery must involve continuing care strategies
*Providers do not need to provide all the required services themselves but must ensure the full array of services is available and coordinated
*Providers must use health information technology (HIT) to facilitate the work and establish quality improvement efforts
Health home
A system of healthcare delivery that aims to provide a generalized structure
and focus when managing the use, access, cost, quality, and effectiveness of healthcare services. Links the client to provider services. The two main types of _______ ____ organizations are Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs). Other types are exclusive provider organization (EPO) and point-of-service (POS) plans.
Managed Care
A single organization or group of affiliated organizations that provides a wide spectrum of ambulatory and tertiary care and services. Care may also be provided across various settings of the healthcare continuum. This is a variety of providers and/or organizations that come together to provide a coordinated continuum of services to a defined population. The goal is to coordinate the seamless delivery of healthcare services.
Integrated Delivery System (IDS)
A program in which contracts are established with providers of medical care. Providers under a _____ contract usually provide better benefits and deliver care at a discounted rate. Covered persons are generally allowed benefits for nonparticipating provider services, usually on an indemnity basis with significant copayments.
Preferred Provider Organization; PPO
A managed care plan that provides benefits only if care is rendered by providers within a specific network.
An ______ is similar to a PPO in that a network of providers have agreed to provide care for the members at a discounted rate. In an ____, however, a patient is not reimbursed for services if he chooses to receive healthcare outside the network.
Exclusive Provider Organization;
EPO
A type of managed care health insurance plan which combines characteristics of both the HMO and the PPO plans. Members of a ____ plan do not make a choice about which approach or plan to use until the point at which the service is needed and is being or about to be used. This plan also requires members to choose a PCP who in turn is responsible to make necessary referrals to SCPs or other healthcare services needed even if outside the plan’s network of providers.
Members usually pay substantially higher costs in terms of increased premiums, deductibles and coinsurance.
This plan allows the patient to choose to receive care in-network at little or no cost or to go out of network and incur larger out-of-pocket expenses.
Point-of-Service Plan; POS
An organization that provides or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium - reimburses providers by capitation (a fixed amount per-member-per-month for contracted services). The primary care physician is often used as a “gatekeeper,” meaning any care (other than emergency care) that is not coordinated through the PCP is not covered.
There are four basic models of ______:
group model,
individual practice association (IPA), network model, and
staff model.
Under the Federal ____ Act, an organization must possess the following to call itself an _____:
(1) an organized system for
providing healthcare in a geographical area,
(2) an agreed-on set of basic and
supplemental health maintenance and treatment services, and
(3) a voluntarily
enrolled group of people.
Health Maintenance Organization (HMO)
Services that are not included in the contract between the provider and the HMO can be “_______ ___” services. This means they are handled by other providers without penalty to the PCP. This is usually done for specialty services, such as transplant or mental behavioral health.
carve out
The HMO contracts with a group of physicians for a set fee per client to provide many different health services in a central location. The group of physicians determines the compensation of each individual physician, often sharing profits. The physicians are employed by the group, not the HMO. The HMO and the group share profits or losses.
Group Model HMO
The fastest growing form of managed care, this plan contracts with a variety of groups of physicians and other providers in a network of care with organized referral patterns. Networks allow providers to practice outside the HMO.
Network Model HMO
A health maintenance organization (HMO) model of insurance that contracts with a private practice physician or healthcare association to provide healthcare services in return for a negotiated fee. The ____ then contracts with physicians who
continue in their existing individual or group practice.
Individual Practice Association (IPA)
The most rigid HMO model. Physicians are on the staff of the HMO with some sort of salaried arrangement and provide care exclusively for the health plan enrollees.
Staff Model HMO
Management of health services to ensure that when offered they are medically necessary, provided in the most appropriate care setting, and at or above quality standards.
Utilization Management (UM)
______________ ________, or precertifications, are done prior to the elective admission or procedure to ensure the requested service is necessary, meets criteria for coverage, and is at the appropriate level of care.
Prospective reviews
A method of reviewing client care and services during a hospital stay to validate the necessity of care and to explore alternatives to inpatient care. It is also a form of utilization review that tracks the consumption of resources and the progress of clients while being treated.
Concurrent review
A form of medical records review that is conducted after the client’s discharge to track appropriateness of care and consumption of resources.
Retrospective review
According to Centers for Medicare & Medicaid Services (CMS), ____ ____ ____ ____ ________ LTAC- also referred to as ___ ____ ____ ______ (LTCH) and _______ ________ - focus on patients whose length of stay is greater than 25 days on average. Many of the patients in LTACs are transferred in from an intensive or critical care unit. LTACs specialize in treating patients who have one or more serious conditions but who may improve with time and care.
long-term acute care hospitals;
long-term care hospitals;
transitional hospitals
Services provided in LTACs typically include:
1.
2.
3.
4.
- comprehensive rehabilitation
- respiratory therapy
- head trauma treatment
- pain management
A healthcare facility that is a step down from an acute care hospital and a step up from a conventional skilled nursing facility intensity of services.
_________ care is for patients who are stable and do not require hospital acute care, but who require more intensive skilled nursing care, therapy, and physician services than are provided to the majority of patients in a SNF. These services may include TPN, IV therapy, wound care, and other therapies such as speech therapy, physical therapy, occupational therapy, and respiratory therapy.
Subacute Care Facility;
Subacute
Inpatient rehabilitation hospitals provide intense, multidisciplinary therapy to patients with a functional loss. To qualify for this level of care, patients must be able to tolerate a minimum of ____ hours of therapy per day, ___ to ___ days per week and be ________ _______.
three hours per day;
5 to 7 days per week;
medically stable
______ _____ ________ offer 24-hour skilled nursing and personal care (e.g. bathing, eating, toileting). They also provide rehabilitation services, such as physical therapy, occupational therapy, and speech therapy. Patients must be medically stable to qualify for ___ level of care. They also must need care from a skilled, licensed professional, such as a nurse or therapist, on a daily basis. Examples are complex wound care and rehabilitation when a patient cannot tolerate 3 hours of therapy per day.
Skilled Nursing Facility;
SNF
A level of care for patients who require more assistance than custodial care and may require nursing supervision, but do not have a true skilled need. Most insurance companies do not cover this care.
Intermediate care
Care provided primarily to assist a client in meeting the activities of daily living but not requiring skilled nursing care. Medical insurance does not cover this level of care.
Custodial care
