Chapter 7: Reimbursement Methodologies Flashcards
What is a claim?
Itemized statement of healthcare services and their costs provided by a hospital, physician’s office, or other healthcare provider; submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider.
What is Fraud and Abuse?
The intentional and mistaken misrepresentation of reimbursement claims submitted to government-sponsored health programs.
What is Medicare?
A federally funded health program established in 1965 to assist with the medical care costs of Americans 65 years of age and older as well as other individuals entitled to Social Security benefits owing to their disabilities.
What is Auditing?
The performance of internal and/or external reviews to identify variations from established baselines.
What is the Prospective Payment System (PPS)?
A type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided.
What is Medicaid?
An entitlement program that oversees medical assistance for individuals and families with low incomes and limited resources; jointly funded between state and federal governments.
What is Public Assistance?
A monetary subsidy provided to financially needy individuals.
What are the Centers for Medicare and Medicaid Services (CMS)?
The division of the department of Health and Human Services that is responsible for developing healthcare policy in the United States and administering the Medicare program and the federal portion of the Medicaid program.
What is the Department of Health and Human Services (HHS)?
The cabinet-level federal agency that oversees all of the health-and human-services-related activities of the federal government and administers federal regulations.
What are Indemnity Plans?
Health insurance coverage provided in the form of cash payments to patients or providers.
What is Group Health Insurance?
A prepaid medical plan that covers the healthcare expenses of an organization’s full-time employees.
What is Major Medical Insurance?
Prepaid healthcare benefits that include a high limit for most types of medical expenses and usually require a large deductible and sometimes place limits on coverage and charges.
What is a Policy Holder?
An individual or entity that purchases healthcare insurance coverage.
Who is an Insured?
A holder of a health insurance policy.
Who is an Insurer
An organization that pays healthcare expenses on behalf of its enrollees.
What is Coinsurance?
Cost-sharing in which the policy or certificate holder pays a preestablished percentage of eligible expenses after the deductible has been met.
What are out-of-pocket expenses?
Healthcare costs paid by the insured after which the insurer pays a percentage of covered expenses.
What is capitation?
A method of healthcare reimbursement in which an insurance carrier pre-pays a physician, hospital, or other healthcare provider a fixed amount for a given population without regard to the actual number or nature of the healthcare services provided to the population.
What is Employer-Based Self-Insurance?
An umbrella term used to describe health plans that are funded directly by employers to provide coverage for their employees exclusively in which employers establish accounts to cover their employees’ medical expenses and retain control over the funds but bear the risk of paying claims greater than their estimates.
What are Premiums?
Amount of money that a policy holder or certificate holder must periodically pay an insurer in return for healthcare coverage.
What is Medicare Part A?
Hospital insurance.
What is Medicare Part B?
Medical (physicians care) insurance.
What is Medicare Part C?
Medicare Advantage.
What is Medicare Part D?
Prescription drug program.
