Chapter 11 Flashcards
Revenue
income received as result of normal business activity
Reimbursement
act of compensating someone for expenses incurred
Worth
monetary units such as a salary; price paid for something
- relatively static
Value
- tangible & intangible
- may increase or decrease depending on circumstance
- changes day-to-day
Steps for any HCP to be reimbursed:
- 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
Functional Outcomes
- objective and subjective measurements using standardized tests/surveys
- used to determine overall effectiveness of care
Types of Insurance Plans:
- Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Point-of-Service
- High-Deductible Health Plan with a Health Savings Account (HCHP)
- Medicare
- Medicaid
- Worker’s Compensation
Health Maintenance Organization (HMO)
- highly restrictive, subscribers must see in-network providers
- premiums and cost share lower
- no deductibles and low copays
Preferred Provider Organization (PPO)
- less restrictive than HMO
- higher premium
- deductible must be met
Point-of-Service
combination of HMO and PPO
- in-network = lower costs
- out-of-network = higher costs (less covered)
High-Deductible Health Plan with a Health Savings Account (HCHP)
- low premiums but high deductibles (HSA account used to pay higher deductibles)
- can see any provider
Medicare
- Federal program for those 65+ years and with disabilities
- many restrictions
- ATs recognized as providers
Medicare A
- hospital insurance
- hospice and home health care
Medicare B
- medical insurance
- lab tests, PT/rehab services, ambulance services
Medicare C
- manages care plans
- MSA
- private fee for service
Medicaid
- 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
Worker’s Compensation
- coverage provided and paid for by employers
- covers injuries at work
- can be administered by state organization or private company
Primary Insurance
first to be responsible for claim
Secondary Insurance
- after primary processes claim, EOB sent to secondary carrier
- secondary schools or college settings
Premium
- amount paid by the subscriber for the policy
- often paid by employer
Deductible
amount the subscriber is responsible for paying before the insurance company takes responsibility for the claim
- protects insurance plan against moral hazard
Co-Pay
- set amount that does not change from visit to visit
- insurance pays balance of claim
Co-Insurance
- applied after the deductible amount has been met by the subscriber
- percentage of remaining balance is distributed between the insurance company and the subscriber
Out-of-Pocket Maximum
total amount the subscriber is responsible for during a plan period
Fee-for-service
billing for each service performed rather than bundled
Visit rate
established amount for all services during a given visit
Case rate
established amount for all services provided for plan of care
In-Network Provider
- treat subscribers and receive a contracted reimbursement rate
- lower rate but higher volume
Out-of-Network Provider
- benefits more limited
- subscriber responsible for greater percentage of claim
Affordable Care Act (March 23, 2010)
encourages providers to form Accountable Care Organizations (ACO)
- network of providers who collaborate on patient care
NPI
identifies HCP who provided services
Current Procedural Terminology (CPT)
- identifies services performed
- indicent or time based
- provider can determine dollar amount, insurance determines reimbursement
- not provider specific
Health Care Common Procedure Coding System (HCPCS)
2 levels of codes
1. Level I: CPT
2. Level II: Alpha numeric
- ambulance
- orthotic/prosthetic devices
- CPT 97032 E-stim
ICD (International Classification of Disease) 10 codes
indicate what conditions for which the patient is being treated
Contracted Provider
- completes contract between themselves and insurance provider
- considered to be in-network
Credential Provider
- provider who completes credentialing process
- additional protection for carrier and members
- council for Affordable Quality Health Care (CAQH)
Explanation of Benefits (EOB)
- generated after carrier processes claim
- explains how claim was processed (how much allowed, written off, assigned to patient, paid to HCP)
Business
legally recognized organization designed to provide goods or services
Steps for opening a business
- what and why?
- Name
- partners
- type of entity
- financial backing
- licenses or certifications
- location
Opening a Business Step 1
What and Why?
- motivating factors
Opening a Business Step 2
Name
- search for name or close derivative (tax ID number)
Opening a Business Step 3
Partners
- sole proprietor (owns business alone)
- partnership (2+ individuals join together)
Opening a Business Step 4
Type of Entity
- Corporation ( individuals invest money, property, or both in exchange for capital stock)
- Limited Liability Corporation (owners considered members)
Opening a Business Step 5
Financial Backing
- establish budget to determine first 6 months and beyond
- loan or investors
Opening a Business Step 6
License and Certification
- identify early
- vary from state to state
Opening a Business Step 7
Location
- affordable and effective
- evaluate economic trends
