Ch. 1-Healthcare Reimbursement and Revenue Cycle Management Flashcards
social insurance (Bismarck) model
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
national health service (Beveridge) model
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)
private health insurance healthcare model
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
US healthcare business model
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)
health insurance
typically covers some portion of payment for healthcare services
connection between US health insurance and employment
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
revenue integrity
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)
three main components of revenue cycle
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)
beneficiary
individual who is eligible for benefits from a health plan
guarantor
first party; responsible for the patient’s health costs
insurance
system of reducing a person’s exposure to risk of loss by having another party (insurance company) assume the risk
integrated revenue cycle (IRC)
coordination of revenue cycle activities under a single leadership and team structure
benefits: reduced cost to collect, performance consistency, and coordinated strategic goals
policyholder
an individual or entity that purchases health insurance coverage
premium
amount of money that a policyholder or beneficiary must periodically pay an insurance company in return for healthcare coverage
reimbursement
amount paid to a healthcare provider for services provided to patient
revenue cycle
regular set of tasks and activities that produce reimbursement (revenue)
revenue cycle management (RCM)
supervision of all the administrative and clinical functions that contribute to the capture, management, and collection of patient service reimbursement
risk pool
group of individual entities(individuals, employers, or associations) whose healthcare costs are combined for evaluating financial history and estimating future costs
single payer health system
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
third party payer
insurance company or health agency that pays the physician, clinic or other provider for the care and services rendered to the patient
universal healthcare coverage
minimum level of healthcare insurance defined by the government; may include coverage for preventative and primary care, hospitalization, mental health benefits, and prescription drugs
