Exam 2 Flashcards
Copay
Flat fee customer pays for each medical service even if out of pocket maximum is met
Coinsurance
Percentage of medical expenses the insured has to pay, even if deductible is met
Premum
Amount of money insured must pay monthly for an insurance policy
Deductible
Specified amount a member must pay before insurance kicks in
What parts of Medicare have most people enrolled, least to greatest
C, D, B, A
Medicare A covers
Hospital expenses
Medicare A is paid for by
Payroll taxes
Medicare B covers
Physician, outpatient services, PT, diabetic testing supplies, vaccines
Medicare part B is funded by
25% from premium, 75% from taxes
Medicare C is funded by
Payments from A, B, D to a private plan
Medicare D covers
Prescription drugs
Medicare D is funded by
25% from enrollee premium, 75% from general taxes
What part of Medicare has the highest expenditures
Part D
What is an alternative payment model
An alternative payment model requires physicians to take responsibility for costs and quality performance to receive payments for providing high value care
Two way shared risk
Payer and provider have agreement to assume risk on both sides. If patient ends up in hospital again, they get less money. If patient provides great care, they get more money. Providers must cover part of healthcare costs if they are unable to maintain patient health
Capitation
There is a fixed amount of reimbursement per diagnosis that is paid ahead of time. If a patient can’t treat a patient within that budget, they lose money
Value-based agreement
Agreement by provider and insurer where they reimbrse healthcare providers based on the quality and value of care they provide
BIN number
Bank Identification Number
PCN
Processor control number, identifies insurance company for the claim
Rx GRP
Group number assigned to identify a member’s group health plan such as employer code
Person code
Identifies relationship to insured
Manufacturer savings card
People with private insurance can use savings cards. Those with government insurance and cash payers can’t use them. The Anti-kick back prevents this by saying its a crime to offer reductions to patients who receive benefits from state/federally funded healthcare programs
Largest healthcare payer in the US
Medicare
Pharmacist provider status as recognized by CMS
Pharmacists are not recognized as providers by CMS. They have to use CT billing codes to be reimbursed. We have to bill at the same level as nurses, hence “incident-to” billing
Incident-to billing takes place n a _____ setting
Noninstitutional setting
Explain incident-to billing process
- Medicare-credentialed physicians must initiate patient care and be involved in treatment, RPh may provide follow-up care
- Physiciand and RPh must be employed by billing entity
- service must be performed in that setting
- Pharmacists can bill to all payers, but do not always get reimbursed
Does a physician have to sign off on pharmacist notes each time?
No, just have to regularly meet
Payment amount for hospital outpatient vs. physician office
Flat rate, depends on complexity of visit
E/M
Evaluation and management billing codes. Codes start with 992. The codes are based on visit, length, complexity of care, and medical decision-making
Medicare coverage gap
“Donut Hole” Temporary limit on Rx coverage by insurance after a limit is reached where you pay a larger amount
catastrophic coverage
When insurance increases coverage once out-of-pocket maximum is reached following coverage gap
Prior authorization
Requires prescriber to justify need for more expensive medication to be covered by insurance
Community pharmacy services that can be billed
Non medications such as POC testing, medical equipment, MTM (CMR, TIPs), vaccines, diabetic testing supplies, CLIA-waved tests
Outcomes MTM Software
MTM software used by pharmacists to bill for services like CMRs and TIPs
what is a TIP
Targeted intervention where the pharmacist talks about a more specific thing such as adherence, gap in therapy, Narcan. Can be billed for simultaneously with CMR
How do patients get populated in Outcomes
Patients are referred to your pharmacy based on the history of filling prescriptions and their insurance plan
Issues related to pharmacy auditing by insurance companies
DAW codes, DIR fees, incorrect Day Supply, Acquisition costs
What are DIR fees
AKA clawbacks, this happens from a loophole in Medicare regulations where payers can take money back on paid clames. Often blamed on performance of quality measures and are typically out f the pharmacys controls
Why are acquisition costs important to get right
Check with wholesalers to get best pricing, having correct costs ensures that you and the pt are not overpaying for medication
Hospital outpatient facility billing
flat payment for all office visits
Physician office (non-facility billing0
Depends on complexity of the visit
Incident to billing must take place in
a noninstitutional setting by a medicare-credentialed physician
Social security act of 1965
This laid the groundwork for Medicare and Medicaid, it started tracking national health expenditures as a percentage of GDP. JFK’s plan to create a healthcare plan for seniors failed but LBJ picked it up and proposed expansion and the Hill-Burton Program that gave government grants to pay for medical practices for those who can’t pay
Establishment of Kaiser Permanente
WW2 and Employer sponsored health care. Kaiser created a program that embedded healthcare costs in employee compensation. During WWII, employers had to find new ways to recruit new employees leading to employee-sponsored health insurance
Establishment of BCBS
WWI and BCBS. After WWI, physicians and hospitals charged more and people couldnt afford it so Baylor Hospitals created aprogram where they would help repay for healthcare expenses. Blue cross=hospital, blue shield = physician
AMA
Did not support progressive legislation over physician compensation. Opposed the Blues bill due to concerns about physician compensatio. AMA and labor unions served as critics
Risk pooling
Group of individuals whose medical costs are combines to calculate premiums and offset costs of people that have to use more healthcare. Larger risk pool leads to more predictable and stable premiums
Insurance reimbursement, greatest to least
Commercial > Medicare > Medicaid
Out of pocket maximum and what counts towards it
Upper bound on an amount the policy holder owes during a policy period before insurance covers 100% of everything. This does not include premiums and copays
HMO
Lowest premium, copay with each visit, coordinate care through PCP, referrals required to see in-network physicians
Lowest premium, pay copay, good if you don’t leave area
PPO
Highest premium, middle deductible, can see PCP or specialist without referral, can see out of network physicians
HDHP
Middle premiums, highest deductible.
Do not need referral, can see out of network. Funds from HSA can be invested and used for healthcare expenses
US trends in hospital utilization, consolidation, healthcare spending
Trend to hospitals consolidating into large conglomerates. Allows for better negotiating power and lower operating costs but leads to higher prices for patients and reduces access to small hospitals
Balance billing by out-of-network providors
Providers that do not contract with insurance provider cost more. Balance billing is where these providers cost customer for cost of service not covered by insured
Ways for hospitals to maximize profits
Adjusting payer mix by increasing number of commercially insured patients, adjusting case mix by increasing specialty since they pay more
Entrepreneurship accelerator program
Help founders start/grow company by providing mentorship, capital, networking, etc
Venture cycle
Rapid growth, lots of cash in bank but not all profit, relocation may be necessary, returns on milestones and growth
lifestyle business
Slow/steady growth, moderate profits, do not have to relocate
VC capital fund cycle
Valley of death: revenue is negative
Capital slowly grows until you meet the public market
Pre seed
Local investor that demonstrates you are a great company leader worth investing in
Seed
Larger geography but the investor must know your market and you must have traction and a good business plan
Series A
Involves national fundraising and a strong venture capital
