CPB 2023 CHAPTER 2 Flashcards
Federal mandate for all persons to have minimal essential coverage for themselves and their dependents
Patient Protection and Affordable Care Act
Pay a penalty as part of their income tax returns
Does not comply with the individual mandate for health insurance
What was repealed in December 2017 as part of the Tax Cuts and Jobs Act and went into effect in 2019?
Individual mandate for health insurance
Employer decides on the type of coverage and costs for insurance made available to eligible employees based on standard of employer.
Group Health Plans
Limited exclusions for pre-existing medical conditions, followed by the pre-existing condition exclusion under the ACA.
HIPAA Law of 1996
Employer contracts directly with the insurance company to hand out certificates to covered employees
Full Insured Employer Group
Employer assumes financial responsibility for the enrollees’ medical claims and incurred administrative costs
Fully Insured Employer Group
Payment for Fully Insured Employer Groups?
Employer pays a premium at a fixed rate for a year based on the number of employees enrolled in the plan..
Insurance companies group together several small employers to form a larger group.
Small Employer Group
Benefit of Small Employer Groups?
Enables the insurance company to better predict the cost of insurance.
Group contracts with an insurance company and third party to handle the paperwork
Self-Funded ERISA
Employer pays for each out-of-pocket claim as it is incurred instead of paying a fixed premium.
Self-Funded ERISA
Signs a contract with a health plan to agree to accept assignment for all covered services furnished to its members and to submit claims for the services provided
Participating Provider (PAR)
What must a participating provider write-off?
Any amounts billed on covered services that were above the negotiated rate
May bill the patient for the difference between the amount billed and the amount paid by the health plan except for Medicare
Non-participating provider (nPAR)
Advantage of PAR?
Health plan agrees to direct covered members to the provider and agrees to pay the provider directly for the services provided
Fee schedule amount is five percent higher?
Medicare participating providers
nPAR Medicare?
Limiting charge applies
What is the percentage of nPAR for Medicare?
115% of the physician fee schedule amount
What state has a limiting charge of 105% instead of 115%?
New York
Providers not limited to any specific charge limit on their patients and do not submit claims to Medicare for their services. Patients sign private contracts regarding payment
Opt-out Medicare Providers
When is the patient responsible for payment in full for services as Medicare will not pay any amount to either the patient or provider?
Opt-out Medicare providers
When is provider open enrollment?
Mid-November to December 31st
What is provider open enrollment?
Time period when providers can change participation status
Program that offers free health benefits counseling to Medicare beneficiaries, their families, or caregivers
State Health Insurance Assistance Program
Educates patients on PAR vs nPAR vs opt-out and what it means for them and free workshops
SHIP
HMO
Health Maintenance Organization
Contracts with a multi-specialty group that provides care to the members
Group Model HMO
Pays an established rate which is distributed to the individual physicians as part of their salaries.
Group is paid in bulk and group is responsible for reimbursing physician members and facilities.
Group Model HMO
Employs the physicians on salary to provide care to members in the clinics and other facilities owned by the organization
Staff Model HMO
Closed-panel HMO
Staff Model
Physicians are contracted to provide medical services to only HMO patients
Staff Model HMO
Contracts with more than one multi-specialty group, individual practice groups, or individual physicians so a variety of services may be offered to its members
Network Model HMO
Allows formation of “provider __”
allows care to be provided in larger geographic areas
Offers the patient a choice of physicians and managed costs
Network Model HMO
Contracts with independent physicians who maintain their offices and provide services to HMO and non-HMO patients
Independent Practice Association (IPA)
Receive a fixed amount per patient
IPA
Open-panel HMO
IPA
HMO may not provide as much coverage for services out-of-network
IPA
Contracts with multi-specialty group practices, IPAs, and independent physicians all together.
Mixed Model HMO
Offer the biggest variety of choices, largest coverage area, more choices of clinics, labs, pharmacies, and hospitals
Mixed Model HMO
Organizations that are affiliated with or own hospitals, physician groups, and other providers that provide a wide range of coordinated health services
MCO
MCO
Managed Care Organizations
Combine the functions of health insurance, delivery of care, and admin
MCO
Manage benefits and develop participating provider networks
MCO
Types of MCO’s
EPO, HMO, IDS, PPO, TOP
Offer provisions that provide insurers with ways to manage the cost, use, and quality of the healthcare services received by group members
MCO
Process of reviewing the appropriateness and quality of care provided to patients
Utilization review - MCO
Authorization for hospital admissions given by a healthcare provider to a group member prior to hospitalization
Preadmission certification - MCO
Requirement designed to encourage patients to obtain routine outpatient services prior to non-emergent admissions, reduces LOS
Preadmission testing - MCO
If the member does not receive services through an in-network provider or facility, the member pays for all costs incurred, unless an emergency
Exclusive Provider Organization (EPO)
Members choose a PCP upon enrollment and pay a percentage of every medical bill up to a yearly maximum out-of-pocket
EPO
Earn more money by charging an access fee to the insurer for use of the network
EPO
Negotiate with the providers of the organization to set fee schedules, help resolve differences, and contract with others to strengthen the network
EPO
Network of affiliated facilities and providers that work together to offer joint healthcare services to members
Integrated Delivery Services
PHO
MSO
GPWW
Types of IDS’
Owned by hospitals and physician groups to develop improved methods of delivery
Physician-Hospital Organization (PHO)
Contract with managed care organizations or directly to employers with joint risk sharing and developing standards of care
PHO
Organized way for physicians and hospitals to work together on utilization management and quality improvement
PHO
Organization that provides:
Administrative duties
Collaborate with managed care companies
Establish physician reimbursement and risk-sharing amounts
PHO
Business that provides nonclinical services to providers like practice management to IPPs
Management Service Organizations (MSO)
Provides a menu of services for providers to select from to meet their needs
MSO
Includes:
Hiring employees, billing and coding personnel, IT personnel, monitoring, implementing policies, compliance, claims submission, appeals, auditing services, managed care contracting and negotiations
MSO
Medical practice formed to share economic risk, expenses, and marketing efforts
Group Practice Without Walls (GPWW)
Several small practices trade under a common tax identification number but retain separate offices and finances
GPWW
Allows providers to jointly negotiate fees and avoid antitrust issues federally
GPWW
Common fee schedule, standardized benefits, and equally shared ancillary service revenue
GPWW
Coporate umbrella for the management of diversified healthcare delivery system
Integrated Provider Organization (IPO)
Physicians practice as employees of the organization or in a closely affiliated physician group
IPO
Can perform services such as:
Evaluate new payer arrangements
Negotiate risk contracts
Credentialing agreements
Annual budgets
IPO
Insurance plan that allows members to choose the doctors and hospitals they prefer within network
Preferred Provider Organization (PPO)
Members can choose not to see a preferred provider but will pay more out-of-pocket costs if provider is nPAR
PPO
Operated by a single insurance plan or a joint venture among two or more insurance payers
Triple option plan
Allows insurers to offer members three different healthcare plans to select the services they want
Triple option plan
What are the three different healthcare plans offered in a triple option plan?
Straight indemnity, HMO, and PPO
Allows the patient to choose any physician and facility of their choosing, the health plan then pays a set portion of the total charges
Straight indemnity plan
usual, customary, and reasonable rates
UCR rates
What are UCR rates utilized for?
To base the reimbursement percentage for payment
The amount that providers in the area where the services were rendered typically charge for the same service
UCR rate
Costlier but gives the patient the most choices
indemnity plan
