Domain 1 Flashcards
Triple Aim
- Improve experience of care
- Improve health of populations
- Reduce per capita cost of care
Managed Care – Healthcare Delivery System
Organizations that provide healthcare to members using contacted providers
Diagnosis Related Group (DRG) System – Coding Methodology
Pays fixed amount for given diagnosis instead of paying all costs related to treatment, Medicare uses
Preferred Provider Organization (PPO) – Managed Care Concept
Contract providers to deliver care at discounted rate, and cover minimal cost for providers not contracted
Exclusive Provider Organization (EPO) – Managed Care Concept
Contract providers to deliver care at discounted rate but do not cover any cost for providers not contracted
Point of Service (POS) – Managed Care Concept
Choose to receive care in network at little to no cost or go out of network and incur larger out of pocket cost
Health Maintenance Organization (HMO) – Managed Care Concept
Pay providers with a fixed amount per member per month, primary care physician is gatekeeper
Acute Care – Level of Care
Most intensive, brief but severe illness, typically provided in hospital
Long-Term Acute Care Hospital – Level of Care
Length of stay greater than 25 days, 1+ serious conditions who may improve with time and care
Subacute Care – Level of Care
Stable, does not require hospital acute care, requires more intensive skilled care/therapy than a regular facility
Inpatient Rehabilitation – Level of Care
Intense, multidisciplinary therapy to patients with functional loss
Skilled Nursing Facility (SNF) – Level of Care
24 hour skilled nursing and personal care, rehab if needed, must be medically stable and require licensed professional
Intermediate Care – Level of Care
Require more assistance than custodial care
Home Health Care – Level of Care
Under Medicare they must be homebound, nursing/therapy to patients in their home
Hospice Care – Level of Care
End of life care (6 months or less) for those with terminal illness, provided in any setting, palliative care, bereavement support for family
Custodial Care – Level of Care
Assists with ADLs and IADLs and medical needs, no licensed worker needed
Assisted Living – Level of Care
Housing and support with ADLs and IADLs, no medical care provided
Medicaid Health Home – Model of Care
Multiple chronic conditions, caring for the whole person (primary and behavioral healthcare), children and adults
Patient Centered Medical Home (PCMH) – Model of Care
Treatment coordinated through primary care, whole person care
Current Procedural Terminology (CPT) – Coding Methodology
Used to report services performed to payers for reimbursement purposes, lists procedures performed
International Classification of Diseases (ICD-10) – Coding Methodology
Used to report medical diagnoses and procedures on claims and to gain data for public health surveillance, diagnosis/reason for encounter with health system
Fee for Service – Reimbursement and Payment Methodology
Each service rendered is priced separately
Bundled Rate – Reimbursement and Payment Methodology
Bundling charges to multiple providers in multiple settings
Case Rate – Reimbursement and Payment Methodology
Flat fee paid to provider for treatment based on diagnoses
Prospective Payment System – Reimbursement and Payment Methodology
Payment is made based on predetermined, fixed amount
Supplemental Security Income (SSI)
Cash assistance for the disabled with limited income and resources
Social Security Disability Insurance (SSDI)
Payment for those who are unable to perform the work they previously did and not able to adjust to other work because of their condition (1 year or longer)
Medicaid
Poor
Medicare (Part A-D)
Old and disabled
A- hospital insurance
B- medical insurance
C- Medicare Advantage Plan
D- prescriptions
1986 Consolidated Omnibus Budget Reconciliation Act (COBRA)
Federal law that allows employees and their families who might otherwise lose their insurance due to certain events to choose to keep it
-Employee death
-Employee job loss/hour reduction
-Employee entitled to Medicare
-Employee divorce/separation
-Child loses dependent status
Indeminity
Benefits in the form of payments instead of services (reimbursement of cost)
Short-Term and Long-Term Disability
Payments for non-work related injury paid by employer and/or employee
Birthday Rule – Coordination of Benefits
If parents are married, parent with birthday first’s insurance is primary for children
Accelerated Dealth Benefit
Insured person with terminal illness can use some of the policy’s benefit prior to dying (deducted after death), no restrictions
Viatical Settlements
Sells life insurance policy of person with terminal/life-threatening illness with life expectancy of less than 5 years to a third party for cash, no restrictions, paid 50-80% of face value
Reverse Mortage
62+, borrows against home’s value without leaving or making payments, no restrictions, repaid after death/selling/moving
Palliative Care
Maintain best quality of life through symptom management
Patient Self-Determination Act
Federal law requiring agencies receiving Medicare and Medicaid reimbursement to recognize living will and POA
Case Management Process (steps in order)
- Screening
- Stratifying Risk
- Assessment
- Planning
- Implementing
- Follow up/Monitoring
- Transitioning/Transitional Care
- Post-transition Communication
- Evaluation
SMART (acronym)
Used to identify attributes of effective goals
S- Specific
M- Measureable
A- Achievable
R- Realistic
T- Time-bound
Adherence
Carrying out the treatment plan correctly
Interdisciplinary/Interprofessional Care Team
Group of healthcare professionals from various disciplines that work together to manage all needs of patient
Critical Access Hospital (CAH) – Level of Care
Small hospitals in rural areas
Short-Term Acute Care Hospital – Level of Care
Provide diagnostic and therapeutic services for 4-5 days
Capitation
Fixed amount paid per month per member to provider for covered costs
Risk Sharing
HMO and provider share responsibility for financial risk/reward involved in cost-effectively caring
Indeminity
Security against possible loss or damages
Stop Loss
Payment may increase after specific dollar threshold is met
Third Party Administrators (TPA)
Organization outside of insuring organization that handles only adminstrative functions
Value Based Purchasing (VBP)
Payment based on outcomes of specific diseases
Hierarchical Condition Category (HCC) – Coding Methodology
Estimates future health care costs for clients
Resource Utilization Groups (RUGS) – Coding Methodology
Pays for nursing facility care based on amount, intensity, and type
Home Health Resource Groups – Coding Methodology
Pays home health agencies for services based on resources used and duration
1974 Employee Retirement Income Security Act (ERISA)
Minimum standards for voluntary retirement and health plans in the private industry
Disease Management
Focus on health promotion and prevention strategies
2010 Patient Protection and Affordable Care Act (ACA)
Act that created health insurance reforms designed to increase access, lower cost, improve quality, add new consumer protections (end pre-existing condition discrimination, end arbirary withdrawals of insurance coverage, keep young adults covered, free preventative care benefits, cover mental health, end dollar limits, pay physicians on value), and increase skill and proficiency of case managers
HUDDLE (acronym)
Stategy to improve communication and facilitate better outcomes
H- Health care
U- Utilizing
D- Deliberate
D- Discussion
L- Link
E- Events
