Domain 1 - Care Delivery and Reimbursement Methods (Part 2) Flashcards
What is the main purpose of Accountable Care Organizations (ACO)?
Main purpose is to improve beneficiary outcomes and increase value of care by providing better care for individuals, better health for populations,
and reducing growth in expenditures (Triple Aim)
What is the purpose of a Medicare Shared Savings Program?
Improve beneficiary outcomes and increase the value of care by providing:
- Better care for individuals
- Better health for populations
- Lower expenditures
What is the purpose of Expansion of Federally Qualified Health Centers (FQHC)?
Their main purpose is to provide primary care services in underserved and rural areas.
What is the meaning of Level of Care?
The level of care is the intensity of resources and services necessary to diagnose, treat, preserve, or maintain an individual’s physical and/or emotional health and functioning.
*The complexity and intensity of case management services are impacted by the context (level) of care setting, client’s health condition and needs, reimbursement method (managed care, capitation, bundled, etc.), type of
care provider, and intensity of resources and services required to meet the needs.
* Levels will vary across the continuum, moving from the least to the most complex (from prevention and wellness, to nonacute, rehabilitation, subacute, and to acute and up to critical) depending on the resources and services necessary at any moment in time
* The levels include prevention and wellness, nonacute, rehabilitation, subacute, acute, and critical
Finish the sentence: Levels will vary across the continuum, moving from…
And what are the levels?
The least to the most
complex (from prevention and wellness, to nonacute, rehabilitation, subacute,
and to acute and up to critical) depending on the resources and services necessary at any moment in time.
The levels include prevention and wellness, nonacute, rehabilitation, subacute,
acute, and critical.
Palliative care aims to:
Relieve suffering and improve quality of life for individuals
with advanced illness and is offered simultaneously with other appropriate medical treatment
Types of insurance:
- Health
- Automobile
- Life
- Disability
- Homeowners/Renters
- Long-term care
Utilization management
Management of health services to ensure appropriate care setting, and at or above quality standards.
Utilization review
A mechanism used by some
insurers and employers to evaluate healthcare services on the basis of appropriateness, necessity, and quality.
VBP
Value Based Purchasing
Organizations and providers can either receive
incentives or penalties for meeting or not meeting quality metrics
* Example – Quality domains are safety, clinical care, efficiency and cost reduction, and client and caregiver-centered experience of care/care coordination
Population health management
A model of care that strives to address patients’ health needs at all points along the continuum of care, including the community setting, by increasing patient participation and engagement
and targeting interventions. The goal is to maintain or improve physical and psychosocial well-being and address health disparities through cost effective, tailored health solutions.
Employee Retirement Income Security Act (ERISA)
ERISA sets uniform minimum standards to ensure that employee benefit plans are established or maintained in a fair and financially sound manner. In addition, employers have an obligation to provide promised benefits and satisfy ERISA’s requirements for managing and administering private retirement and welfare plans.
* Applies to voluntary health plans (benefit plans) in private industry, specifically for self-insured employer groups
Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)
Requires certain employers to allow qualified employees, spouses, and dependents to continue health insurance coverage when it would otherwise stop (upon leaving employment, death of employee)
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- Came about with electronic records and transfer of information
- Protects individual health records and personal health information (PHI)
- Limits release of information to minimum reasonable needed for the disclosure
- Also includes regulations for fraud and abuse
- Gives individuals rights to their own health records
Liability insurance
benefits paid for bodily injury, property damage, or both
Workers’ compensation
Plan that provides medical benefits and lost wages for
persons who have an illness or injury caused by or occurring because of work. Focus
on return to work. Heavy use of case management.
Accident and health insurance
Includes payment for health-related costs. May have maximum limitations and may include long- or short-term disability for salary
replacement
Indemnity
Security against possible loss or damages. Covered loss reimbursement paid in predetermined amount. In health insurance, these plans are also known as “fee for service” plans. Gives greatest amount of flexibility and freedom. Can be more costly
Medicare
Intended to finance medical care for persons age 65 and older or the disabled who are entitled to social security benefits
Medicare Part A covers:
Part A covers hospital, skilled nursing care, nursing home (with skilled need), hospice, home health care
Medicare Part B covers:
Part B covers physician, outpatient, ambulance, clinical research, and mental health services
Medicare Part D covers:
Part D covers prescription drugs
Medicare Advantage
- Created by the Balanced Budget Act of 1997
- Option for Medicare enrollees
- Provided by private insurance plans
- Provides many services normally received under traditional Medicare with
additional benefits - Managed care plans, networks are based on plan contracts and may be narrow
Secondary Medicare Insurance
- For Medicare beneficiaries who do not participate in Medicare Advantage Plan
- Covers co-pays and other financial responsibilities not covered by traditional Medicare
Medicaid
- Finances health care of indigent and other special designated groups
Proprietary and Confidential. May not be reproduced or redistributed. - Financed jointly by federal and state governments
- Eligibility criteria vary from state to state
- Based on income, assets, and dependents
Managed Medicaid
- Like Managed Medicare for Medicaid recipients
- Focus on cost containment, improved access, and quality of care
- Provides many healthcare services a Medicaid recipient would normally receive on a prepaid capitated basis
- May have narrow networks
Is Worker’s Compensation federally mandated or state mandated?
State mandated