Chapter 2: Providers Flashcards
Blue Cross and Blue Shield
- Healthcare organization
- Each subscriber pays a set fee in order to receive services
What is a PPO?
Preferred Provider Organization
- Contract with Employers, insurers, or third party organizations to provide services at a reduced fee
- A PPO subscriber can still receive care from a provider out of network but it will cost more
Medicare
- Government insurance program
- for ages 65 and older
- Social security provides information and encourages enrollment
Medicaid
Title XIX
- To help needy persons regardless of age
- Financed by both state and federal gov.
State Workers Compensation Program
- To compensate employees for lost wages and medical expenses due to occupational accidents
- Misconduct is not covered
Self-Insurance
- Employer funds and pays for member claims and benefits
- The employers premiums are directed into a trust from which the plans benefits and claims are paid
- Trust are also called 501(c)(9)
Partially self-insured plan
An employee may share the risk of covering claims by buying stop-loss insurance coverage from an insurance company
MET
Multiple Employer Trusts
- Method of marketing group benefits to employers who have a small number of employees
- Can provide a single type of insurance or a wide range of coverages
- Employer must subscribe to trust first before using METs
MEWA
Multiple Employee Welfare Arrangements
- Consists of small employers who have joined to provide health benefits for their employees
- Tax-exempt entities
- Employees must have an employment related common bond
Name some types if Health Insuring Corporations
- Physicians
- outpatient hospital and medical
- Urgent care
- Lab services
- Radiological services
Prepayment Plan
A Health Insurance Corp. (HIC) Operate in a prepayment basis which then entitles the insured to a wide range of services
Managed care
Organized method of providing health care services and involves a third party in the planning, approval and monitoring of a subscriber
Gatekeeper Concept
- Requires subscribers to choose a primary care physician from a list
Prior Authorization
- Ensure that treatment is medically necessary according to doctor
- Cost control measure
Capitation
The amount received by a primary care physician from the health insurance corporation (HIC)
- Based on members per month physician has received
Service Area
Geographical are of the state the HIC is licensed to operate
Evidence of Coverage
Coverage and services provided and the rights of the subscriber
What three cases can an HIC release subscriber information?
- Consent of subscriber is given
- A court order
- Litigation between the enrollee and the HIC
Open Enrollment for HICs
- Open enrollment for at least 30 days
Cancelation of coverage under these five rules:
- Fails to pay fixed periodic premiums
- Engaged in fraud or forgery
- Engaged in material misrepresentation
- Engaged in unauthorized use of an ID card
- Unable to maintain or establish a physician/patient relationship
Coverage of Newborn Children
Coverage for 31 days after birth then parent must notify HIC to continue coverage after 31 days
Healthcare Maintenance Organization (HMO)
- Group enrollment system
- Prepaid services to take preventative measures in their health
- More costly procedures can be avoided this way
Four parts of Medicare
Part A: Pay inpatient hospital care, home health, nursing/hospice (100 days)
Part B: Pays for doctors services and other services not covered by hospital insurance (optional) 80% coverage. Jan 1 to March 31 enrollment perid
Part C: Services offered approved HMOs or PPOs. Must be Enrolled in both A and B
Part D: access to private prescription drug plans
HIC
Health Insurance Corporation
- Operates on a reimbursement basis
- Works with primary care physicians
- Medical, dental, feet…. (not outpatient medical)
A health care provider claim can be settled with what kind of payment method?
Fee-for-service payment method
