chapter 8 Flashcards
third-party payer
private or government organization that insures or pays for health care on behalf of beneficiaries
preferred provider organization (PPO)
managed care network of health care providers who agree to perform services for plan members at discount fees
Health maintenance organization (HMO)
health care system in witch providers offer health care to members for fixed periodic payments.
Primary care physician (PCP)
physician in a managed care organization who directs all aspects of a patients care
point-of-service (POS) plan
managed care plan that permits patients care plan that permits patients to receive medical services from nonnetowrk providers
consumer-driven (directed) health plans (CDHP)
medical insurance that a high- deductible health plan with one or more tax- preferred savings accounts that the patients
High- deductible health plan (HDHP)
health plan that combines high- deductible insurance and a funding option to pay for patients out-of-pocket expenses up to the deductible
Health reimbursement account (HRA)
consumer-driven health plan funding option where an employer sets aside an annual amount for health care costs
Health saving accounts (HSA)
consumer- driven health plan funding option under which funds are set aside to pay for certain health care cost
Flexible saving account (FSA)
consumer-driven health plan funding option that has employer that has employer and employee and employee contributions
Group health plan (GHP)
plan of an employer or employee organization to provide health care to employees, former employees, and/ or their families
federal employees health benefits (FEHB)
Health care program that covers federal employees
Self- insured health plans
health insurance plans paid for directly by the organization, which sets up a funds which to pay
self-insured health plans
a law providing incentives and protection for copies with employee health and pension plans
Individual health plans (IHP)
medical insurance plan purchased by an individual
Blue cross and blue shield association (BCBS)
licensing agency of blue cross and blue shield plans
medicare
federal health insurance program for people sixty-five or older and some people with disabilities
medicare part A hospital insurance (HI)
program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care
Medicare Part B, supplementary medical insurance (SMI)
program that pays for physician services, outpatients, hospital services, durable medical equipment, and other services and supplies
original medicare plans
medicare fee-for-service plan
Medigap
plan offered by a private insurance carrier to supplement insurance carrier to supplement medicare coverage
medicare part C, medicare advantage
managed care health plans under the medicare program
Medicare Part D
Medicare prescription drug reimbursement plans
Medicaid
federal and state assistance program that pays for health care services for people who cannot afford them
Medi-Medi beneficiary
person eligible for both medicare and medicaid
Dual-eligible
medicare- medicaid beneficiary
TRICARE
government health program serving dependents of active- duty service members, military retirees and their family some former spouses and survivors of deceased military members
Civilian health and medical program of the department of veterans affairs (CHAMPVA)
Health care plans for families of veterans with 100 percent service- related disability and the surviving spouse and children of veterans who die from service related disabillityl
Workers compensation insurance
states of federal plan that covers medical care and other benefits for employees when suffer accidental injury or become ill as a result of employment
disability compensation programs
programs that provide partial reimbursement for lost income when a disability prevents an individual from working
fee schedule
document that specifies the amount the provider bills for services
usual fees
normal fees charged by a perovider
usual, customary and reasonable (UCR)
fees set by comparing usual fees, customary fees and reasonable fees
relative value scale (RVS)
system of assigning unit values to medical services based on their required skill and time
resource- base relative value scale (RBRVS)
relative value scale for establishing medicare charges
Medicare physician fee schedule (MPFS)
RBRVS0 based allowed fees that are the basis for medicare reimbursements
Allowed charge
Maximum charged a plans pays for services or procedure
Balance billing
collecting the difference between a providers usual fee and a payers lower allowed charged
write off
to deduct an amount from a patients account
Discounted fee-for- services
payment schedule for services based on a reduced percentage of usual charged
Capitation (CAP) rate
periodic prepayment to a provider for specified services to each plan member
