Exam 3: Health Care Information Flashcards
complementary medicine
practices and products of non-mainstream origin
integrative health
incorporate complementary approaches into the mainstream health care
alternative medicine
using a non-mainstream approach in place of conventional medicine
premium
what you pay monthly for insurance
Co-pay
what you have to pay each time you visit a health care provider’s office or fill a prescription
Deductible
The amount you have to pay before insurance begins to cover costs
co-insurance
the percentage you have to pay once the deductible has been met
maximum amount out-of pocket costs
after you reach this level, any additional health care for this calendar year is free
Three key aspects of insurance reimbursement
1) Coverage - the service covered by the insurance plan 2) reimbursement amount - how much will the insurance pay for it 3) Documentation/coding - Has the appropriate documentation and coding been completed?
What drives the services that insurance companies will pay for?
Medicare: services that medicare pays for or reimburses is modeled off of medicare.
Diagnosis-related groups
(simply pricing and reimbursement) Groups of patients with the same diagnosis have common demographic, diagnostic and therapeutic attributes that determine their resource needs
Sets a rate that Medicare will reimburse
Any additional expense is paid by the hospital
Example-appendectomy-$5500-18,000
CPT codes
Current Procedural Terminology 1) Established by the Centers for Medicare and Medicaid services 2) Identify medical care interventions 3) Specific for health profession 4) If there isn’t a code you can’t ask for insurance reimbursement
ICD-10 Codes
International Statistical Classification of Diseases and Related Health Problems
1) Medical classification list
2) Contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease
CPT vs ICD-10
CPT - identifies “what you did” ICD -10 “ The diagnosis that identifies why you did what you did”
NPI
National Provider identifier : Identifies health care providers in the U.S used by the CMS
EIN
Employer identification number: used by employers for the purpose of paying taxes.
Superbill
receipt to submit to insurance companies; CMS 1500 claim form most commonly used superbill
Medicare
People over the age of 65; under the age of 65 with disabilities, and at any age for individuals with end-stage renal disease
FICA
Federal Insurance Contribution Act; Employer and employee contribute equally (self-employed have to pay for both)
Medicare Part A
Hospital insurance ; 1) Inpatient care hospital or rehabilitation 2) Skilled nursing facility (maximum of 100 days coverage) 3) Hospice Care 4) Home Health 5) Premium Free
Medicare Part B
Medical; 1) Premium paid each month directly to insurance company 2) Doctors’ Services 3) Preventive Services 4) Outpatient Hospital Visits 5) Emergency Room Visits 6) Durable Medical Equipment
7) Other services and supplies
Medicare Part D
Prescription; Prescription drugs only, Brand drugs and generic, No over-the-counter drugs
Medicaid
Income based, health care payed for by state and federal government, covers more than 60% of all long-term care residents
Identify the accreditation sought by the majority of hospitals and health care facilities in the U.S. What is the main goal of this accrediting body
1) The joint commission 2) goal is to ensure that people get the safest, high quality, best-value health care across all hospitals
Primary Care
First point of consultation (Family practitioners)
Secondary health
Curative, not preventative (medical specialists)
Tertiary
Highly specialized; 1) Personnel and facilities for advanced medical investigation and treatment
ex: intensive care unit, burn unit, bone marrow transplant
Quaternary care
highly specialized and not widely available; Research, experimental medicine, and some types of uncommon diagnostic or surgical procedures
Levels of Trauma Care
Basic (Level: IV) ; Level I ( comprehensive trauma)
restorative care
1) Brain injury, spinal cord injury, stroke, orthopedic, or neurological illnesses/injuries 2)Reach as high a functional level as possible
Not-for-profit hospitals
view as charities by IRS do not pay federal income, state or property taxes, tend to provide more uncompensated care
