Case Mangement Chapter 3: Reimbursement Concepts

Question 1

Describe various methods of remimbursement

Answer 1

Cost- sharing (used by most insurance companies- co-pays, coinsurance, deductible), Reinsurance (stop-loss), Defferred liability (Medicaid), Third Party liability (MVAs, work-comp, home-owners, auto), Carve-out (replaces or carves out portion of coverage), Limits (in and out of network).

Question 2

Define PPS

Answer 2

Protective Payment System. Introduced in 1983. DRGGs.

Question 3

Per diem

Answer 3

fixed dollar amount per day

Question 4

Capitation

Answer 4

allows health plan to budget for certain costs. Fixed monthly payments to provider, paid in advance, regardless of services provided.

Question 5

Discounted fee-for-service

Answer 5

reimbursement discounted

Question 6

Fee-fo-service

Answer 6

Watch out if hospital paid by HMO thru capitation, high risk for hospital

Question 7

Pay-for-Performance

Answer 7

incentives

Question 8

Bundling and Unbundling

Answer 8

Includes everything from anesthesia to surgeon to post-op care vs. everything billed separately.

Question 9

Define Managed Care Organization

Answer 9

Provides and/or finances medical care using provider payment mechanisms that encourage cost-containment, involve selected contracting networks, and imposes controls on utilization

Question 10

Commercial/Private Insurance

Answer 10

Liability, no-fault auto and workers comp, accident and health, indeminity (paid on predetermined amounts), stop-loss, managed care plans, Union health

Question 11

Government

Answer 11

Medicare, Medicaid, Military, Federal employee, Indian Health

Question 12

Medicare

Answer 12

Federally funded, Title XIX of Social Security Act. Greater than 65 y.o., workded for at least 10 years (40 quarters). Less than 65 y.o. with certain disabilities (ESRD).

Question 13

Medicare part A

Answer 13

hosptial insurance, usually premium free, earned on person’s or spouse’s employment credits; finacnced through FICA, portion of SS tax. Those who purchase part A must also purchase part B.

Question 14

Medicare part B

Answer 14

MD services, DME, outpatient, and other misc. not covered by part A. Can be purchased withough Part A.

Question 15

Medicare part C

Answer 15

HMOs, PPOs approved by Medicare and run by private companies.

Question 16

Medicare part D

Answer 16

Rx coverage

Question 17

Medigap

Answer 17

Approved in 1992; fills the gaps of medicare (supplemental)

Question 18

Medicare Select

Answer 18

Medigap plans in some states, supplements traditional Medicare.

Question 19

Medicaid

Answer 19

Funded under title XIX of SS Act (1964); income and AFDC based. Federal gov. establishes guidelines but requirements established by each state. Recipients of SSI and those who qualify for AFDC are automatically eligible for Medicaid.

Question 20

MAO

Answer 20

Medical Assistance Only is special category of Medicaid recipients under AFDC of SSI who recieve only Medicaid but not financial assistance.

Question 21

SOBRA

Answer 21

Sixth Omnibus Budget Reconciliation Act- pregant women and children under poverty level eligible. Also people with certain medical conditions (uninsured breast/cervical cancer, TB, blind and disabled that are receiving SSI

Question 22

Reimbursement strategies of case manager:

Answer 22

Matching needed service for patients with available resources; need basic understanding of insurance types (what benefits are, what is covered, how services are reimbursed, patient fiscal responsiblities, whom patient is allowed to f/u, where patient must fill Rx)