Ch. 1-Healthcare Reimbursement and Revenue Cycle Management

Question 1

social insurance (Bismarck) model

Answer 1

universal healthcare; every worker and employer contributes to a sickness fund(agencies that collect and redistribute funds per government regulations); contributions proportionate to income; workers can choose which fund they contribute to

Question 2

national health service (Beveridge) model

Answer 2

government-run; government owns the hospitals and clinics as well as pays doctors and other healthcare professionals; financed by country’s general revenue(from taxes that increase based on income)

Question 3

private health insurance healthcare model

Answer 3

many insurance companies exist; companies collect premiums to create a pool of money which is used to pay health claims; workers and employers contribute but contributions are determined by the company not the worker/employers income

Question 4

US healthcare business model

Answer 4

5 relationships between 4 parties
1-patient and provider (patient receives care/services from provider)
2-provider and third-party payer (provider submits invoice to payer and payer submits payment to provider)
3-third-party payer and patient’s employer (employer pays all or portion of premium on behalf of patient, if applicable)
4-patient and patient employer (insurance payments are taken out during payroll processing and patients may be allowed to select a specific health plan if multiple options are given)
5-patient and third-party payer (represents precertifications the patient’s health plans may require and direct payments from patient to payer)

Question 5

health insurance

Answer 5

typically covers some portion of payment for healthcare services

Question 6

connection between US health insurance and employment

Answer 6

health insurance is typically offered through employers; large employers pay a portion of the premium; if a person loses their job they often lose their health insurance

Question 7

revenue integrity

Answer 7

performing revenue cycle duties to obtain operational efficiency, compliance, adherence, and legitimate reimbursement
-goal: for claims to be clean(free of errors), complete(all services and supplies reflected), and compliant(adhering to contract requirements, regulations, and laws)

Question 8

three main components of revenue cycle

Answer 8

Front end processes: patient engagement (prior to patient receiving care)
Middle processes: resource tracking (while patient is receiving care and shortly after discharge)
Back end processes: claims production and revenue collection (after patient is discharge until reimbursement is received)

Question 9

beneficiary

Answer 9

individual who is eligible for benefits from a health plan

Question 10

guarantor

Answer 10

first party; responsible for the patient’s health costs

Question 11

insurance

Answer 11

system of reducing a person’s exposure to risk of loss by having another party (insurance company) assume the risk

Question 12

integrated revenue cycle (IRC)

Answer 12

coordination of revenue cycle activities under a single leadership and team structure
benefits: reduced cost to collect, performance consistency, and coordinated strategic goals

Question 13

policyholder

Answer 13

an individual or entity that purchases health insurance coverage

Question 14

premium

Answer 14

amount of money that a policyholder or beneficiary must periodically pay an insurance company in return for healthcare coverage

Question 15

reimbursement

Answer 15

amount paid to a healthcare provider for services provided to patient

Question 16

revenue cycle

Answer 16

regular set of tasks and activities that produce reimbursement (revenue)

Question 17

revenue cycle management (RCM)

Answer 17

supervision of all the administrative and clinical functions that contribute to the capture, management, and collection of patient service reimbursement

Question 18

risk pool

Answer 18

group of individual entities(individuals, employers, or associations) whose healthcare costs are combined for evaluating financial history and estimating future costs

Question 19

single payer health system

Answer 19

one entity acts as an administrator of a single insurance pool; they collect all health fees (taxes or contributions) and pays all health costs for an entire population; entity can be an agency of the government or a government-run organization

Question 20

third party payer

Answer 20

insurance company or health agency that pays the physician, clinic or other provider for the care and services rendered to the patient

Question 21

universal healthcare coverage

Answer 21

minimum level of healthcare insurance defined by the government; may include coverage for preventative and primary care, hospitalization, mental health benefits, and prescription drugs