Chapter 11

Question 1

Revenue

Answer 1

income received as result of normal business activity

Question 2

Reimbursement

Answer 2

act of compensating someone for expenses incurred

Question 3

Worth

Answer 3

monetary units such as a salary; price paid for something
- relatively static

Question 4

Value

Answer 4

• tangible & intangible
• may increase or decrease depending on circumstance
• changes day-to-day

Question 5

Steps for any HCP to be reimbursed:

Answer 5

• Pt must be injured and seek care
• Pt must be subscriber of insurance payer
• HCP must be willing to bill insurance carrier
• Carrier must be willing to pay the HCP for services rendered

Question 6

Functional Outcomes

Answer 6

• objective and subjective measurements using standardized tests/surveys
• used to determine overall effectiveness of care

Question 7

Types of Insurance Plans:

Answer 7

1. Health Maintenance Organization (HMO)
2. Preferred Provider Organization (PPO)
3. Point-of-Service
4. High-Deductible Health Plan with a Health Savings Account (HCHP)
5. Medicare
6. Medicaid
7. Worker’s Compensation

Question 8

Health Maintenance Organization (HMO)

Answer 8

• highly restrictive, subscribers must see in-network providers
• premiums and cost share lower
• no deductibles and low copays

Question 9

Preferred Provider Organization (PPO)

Answer 9

• less restrictive than HMO
• higher premium
• deductible must be met

Question 10

Point-of-Service

Answer 10

combination of HMO and PPO
- in-network = lower costs
- out-of-network = higher costs (less covered)

Question 11

High-Deductible Health Plan with a Health Savings Account (HCHP)

Answer 11

• low premiums but high deductibles (HSA account used to pay higher deductibles)
• can see any provider

Question 12

Medicare

Answer 12

• Federal program for those 65+ years and with disabilities
• many restrictions
• ATs recognized as providers

Question 13

Medicare A

Answer 13

• hospital insurance
• hospice and home health care

Question 14

Medicare B

Answer 14

• medical insurance
• lab tests, PT/rehab services, ambulance services

Question 15

Medicare C

Answer 15

• manages care plans
• MSA
• private fee for service

Question 16

Medicaid

Answer 16

• federal program administered by states
• 2 eligibility requirements:
  1. fall below certain income limits
  2. disability
• covered services vary by state
• many student athletes covered

Question 17

Worker’s Compensation

Answer 17

• coverage provided and paid for by employers
• covers injuries at work
• can be administered by state organization or private company

Question 18

Primary Insurance

Answer 18

first to be responsible for claim

Question 19

Secondary Insurance

Answer 19

• after primary processes claim, EOB sent to secondary carrier
• secondary schools or college settings

Question 20

Premium

Answer 20

• amount paid by the subscriber for the policy
• often paid by employer

Question 21

Deductible

Answer 21

amount the subscriber is responsible for paying before the insurance company takes responsibility for the claim
- protects insurance plan against moral hazard

Question 22

Co-Pay

Answer 22

• set amount that does not change from visit to visit
• insurance pays balance of claim

Question 23

Co-Insurance

Answer 23

• applied after the deductible amount has been met by the subscriber
• percentage of remaining balance is distributed between the insurance company and the subscriber

Question 24

Out-of-Pocket Maximum

Answer 24

total amount the subscriber is responsible for during a plan period

Question 25

Fee-for-service

Answer 25

billing for each service performed rather than bundled

Question 26

Visit rate

Answer 26

established amount for all services during a given visit

Question 27

Case rate

Answer 27

established amount for all services provided for plan of care

Question 28

In-Network Provider

Answer 28

• treat subscribers and receive a contracted reimbursement rate
• lower rate but higher volume

Question 29

Out-of-Network Provider

Answer 29

• benefits more limited
• subscriber responsible for greater percentage of claim

Question 30

Affordable Care Act (March 23, 2010)

Answer 30

encourages providers to form Accountable Care Organizations (ACO)
- network of providers who collaborate on patient care

Question 31

NPI

Answer 31

identifies HCP who provided services

Question 32

Current Procedural Terminology (CPT)

Answer 32

• identifies services performed
• indicent or time based
• provider can determine dollar amount, insurance determines reimbursement
• not provider specific

Question 33

Health Care Common Procedure Coding System (HCPCS)

Answer 33

2 levels of codes
1. Level I: CPT
2. Level II: Alpha numeric
- ambulance
- orthotic/prosthetic devices
- CPT 97032 E-stim

Question 34

ICD (International Classification of Disease) 10 codes

Answer 34

indicate what conditions for which the patient is being treated

Question 35

Contracted Provider

Answer 35

• completes contract between themselves and insurance provider
• considered to be in-network

Question 36

Credential Provider

Answer 36

• provider who completes credentialing process
• additional protection for carrier and members
• council for Affordable Quality Health Care (CAQH)

Question 37

Explanation of Benefits (EOB)

Answer 37

• generated after carrier processes claim
• explains how claim was processed (how much allowed, written off, assigned to patient, paid to HCP)

Question 38

Business

Answer 38

legally recognized organization designed to provide goods or services

Question 39

Steps for opening a business

Answer 39

1. what and why?
2. Name
3. partners
4. type of entity
5. financial backing
6. licenses or certifications
7. location

Question 40

Opening a Business Step 1

Answer 40

What and Why?
- motivating factors

Question 41

Opening a Business Step 2

Answer 41

Name
- search for name or close derivative (tax ID number)

Question 42

Opening a Business Step 3

Answer 42

Partners
- sole proprietor (owns business alone)
- partnership (2+ individuals join together)

Question 43

Opening a Business Step 4

Answer 43

Type of Entity
- Corporation ( individuals invest money, property, or both in exchange for capital stock)
- Limited Liability Corporation (owners considered members)

Question 44

Opening a Business Step 5

Answer 44

Financial Backing
- establish budget to determine first 6 months and beyond
- loan or investors

Question 45

Opening a Business Step 6

Answer 45

License and Certification
- identify early
- vary from state to state

Question 46

Opening a Business Step 7

Answer 46

Location
- affordable and effective
- evaluate economic trends