Exam 2 (wk 5-8) Flashcards
Chapters 30, 63, 12, 14, 27, 48, 29, 7, 46
Affordable Care Act (ACA)
Obamacare
U.S. federal statute
ACA marketplace exchanges
organizations created to allow individuals to compare and purchase private health insurance plans and facilitate access to tax credits that make those plans more affordable
in 2016, private health insurance accounted for
67.5% of coverage
most common subtype of private health insurance
employer-sponsored insurance
out-of-pocket expense
clients’ monthly payment to access insurance plan
deductible
set amount of money that a client must pay out of pocket each year prior to being authorized to obtain services at no or lower cost under the plan
copayment
set amount of money client must pay for each health care practitioner visit
coinsurance
money that a client is required to pay for services and is often specified by a percentage
ex: client pays 20% toward service charges and insurance pays 80%
coverage policies
contract between the health insurance company and and the policyholder (individual, group, organization) that delineates covered and non-covered services
covered healthcare services
services paid for in full under insurance policy
non-covered healthcare services
services not paid for in full under policy
indemnity
allow clients to visit almost any doctor or hospital they prefer
insurance then pays a set portion of the total charges
indemnity plans are also known as
fee-for-service plans
health benefits
a condition of employment after Taft-Harley Act
subject to bargaining
healthcare products and services that are covered in whole or part by a health plan
self-funded group health plans
aka self-insured plan
a health care benefit plan where the employer is responsible for paying most of the health bills, not just the insurance premiums
managed care
a continuum of arrangements that integrate the financing and delivery of healthcare
health maintenance organizations (HMOs)
pays for medical care only within their network of care providers
less cost
preferred provider organizations (PPOs)
covers more medical cost if patient receives care within network of providers
still pays some outside the network
point of service (POS)
patients can choose between PPO and HMO with each visit
exclusive provider organization (EPO)
services are only covered if patients go to doctors, hospitals, and specialists within the network (except in emergencies)
limited coverage with doctors, specialists or hospitals in the plan’s network
healthcare payment learning and action network (LAN)
Help advance the work being done across private, public, and nonprofit sectors to increase the adoption of value-based payments and additional new, innovative payment and care delivery models, often called alternative payment models
private employment-based group health plans are regulated by
U.S. Department of Labor
nonfederal government health plans are regulated by
U.S. Department of Health and Human Services
in-network
health care providers contracted into a health plans
out-of-network
providers who are not contracted or excluded from health plans
key questions to ask about coverage
Definition of OT
Limitations (visits, sites, costs)
Network of providers
Case management
Fee-for-service or bundle
Credentials for OT
Subscriber responsibility (copayment, deductible, other out-of-pocket)
billing responsibilities for OT managers
- Understand different coverage limitations, billing procedures, documentation requirements, and authorization processes, which may vary by payer
- Be aware of how OT services are regulated by the state(s) in which they practice, or in which the practitioners they oversee are practicing
- Teach and educate direct reports on how to submit charges and properly bill for services
- Create departmental policies and procedures, according to relevant laws, regulations, policies and rules
- Understand penalties clinicians can face for not properly billing for services and consequences they can face due to fraud and abuse
- Seek advice, education, consultation or services from billing experts, when needed
billing responsibilities for OTs
- Understand different coverage limitations, billing procedures, documentation requirements, and authorization processes, which may vary by payer
- Understand penalties clinicians can face for not properly billing for services and consequences they can face due to fraud and abuse
- “Occupational therapy practitioners cannot ignore the increasing number and complexity of laws,
regulations, and other rules that govern federal reimbursement and other health care programs….all face increased scrutiny in what they do and how they bill for it ”
penalties clinicians can face for not properly billing for services and consequences they can face due to fraud and abuse
Lose license
Barred for life from billing Medicare
Incur large fines
Go to jail
Criminal and civil liability
HHS, DOJ, OIG, formed
Health Care Fraud Prevention and Enforcement Action Team (HEAT) in high fraud cities
funded by the Omnibus Appropriations Act
False Claims Act
federal law that protects the government from fraud and abuse
makes it illegal to:
1. Knowingly submit false claims to the government
2. Cause someone to submit false claims to the government
3. Knowingly use false record material to a false claim
4. Improperly avoid an obligation to pay the government
Medicare fraud
knowingly submitting false claims or making misinterpretations of fact to obtain payment
knowingly soliciting, offering, receiving, or paying remuneration to induce reward referrals for items or services reimbursed by federal healthcare
making prohibited referrals for certain healthcare services
Medicare abuse
practices that directly or indirectly result in necessary cost to Medicare
Anti-Kickback Statute
limit influence of financial incentives on healthcare
makes it a criminal offense to knowingly or willingly offer, pay, solicit, or receive any payment to induce or reward referrals of items or services reimbursable by a federal healthcare program
Stark Law
prohibits providers from referring Medicare patients for certain “Designated Health Services” to an entity with which the physician has a relationship
prevents physicians from benefitting from their referrals
Civil Monetary Penalty Law
authorizes the imposition of substantial civil penalties or very large fines against entities who engage in prohibited activities
False Claims Act
“whistleblower law”
imposes liability on anyone who knowingly submits false claims to the government
HIPAA
Health Insurance Portability and Accountability Act
a federal law that protects patients’ health information and establishes standards for electronic health information
current procedural terminology
billing code system used by the healthcare industry
numerical codes assigned to each intervention or treatment, referred to as “procedure code”
help insurers determine amount of reimbursement for a given service
billed individually, separately or as a group or “bundled” billing codes
National Correct Coding Initiative
limits which codes can be billed together for the
same patient
Upcoding
billing for codes that reimburse at a higher rate instead of services
actually provided
Unbundling
billing for codes separately instead of as a group
safe harbors
allowable business arrangements that would escape prosecution under AKS
marketing
the process of identifying a set of strategies to communicate with potential consumers to attract and
persuade them to use your services
objectives of marketing
Meet the objectives of the company aligned to mission, vision and strategic plan priorities; social, managerial, financial, and operational objectives
Identifying and meeting customer needs
Creating awareness of the service/ product and increasing access
Develop standards and policies that ensure the quality of services
Promote goodwill
Build consumer loyalty, ensure value and satisfaction
target market
a specific group of consumers or clients at whom a company aims its products and services
3 primary target markets
- Clients and potential clients
- Payers
- Referral sources (Social media “influencer”)
niche market
Subset of the market in which services
or products are focused
Example:
Market = seniors
Niche Market = seniors with hip
replacement
Product = reachers
marketing mix/promotional mix
the tactical, controllable, and operational components of a marketing plan that may be combined to produce
the desired response form the target market
