FINANCIAL CONSIDERATIONS Flashcards
these must be collected at the time of service to increase cash collections for practice, which supports the revenue cycle…
Out-of-pocket expenses
it is not considered as part of the cost share
it must be paid monthly
it is paid by insured or employer
it is mandatory
Premium
it must meet a certain amount yearly
it is paid by insured
it is a fixed amount
it must be paid before insurance will start paying for the covered benefits
Deductible
deductible must be paid before this takes place
it is the amount shared with the Payer and Insured
the Payer usually pays more
Coinsurance
it is paid at the time of service
it is a fixed amount
the amount of payment varies on type of visit
Copayment
it is the most a member/family pay out of pocket for that given year
Out of Pocket Maximum (OOPM)
patients who do not have insurance and pays in these ways
Self-pay pts, self-pay or private pay
another payment option where it’s offered as employee benefits during open enrollment
the funds are tax-exempt
employer deducts a set amount from ea paycheck
Health Savings Account (HSA)
this form serves as informed consent to transfer responsibility to the patient if Medicare does not pay for the service
documents the beneficiary’s decision about a service or procedure that Medicare may cover
Advance Beneficiary Notice of Noncoverage (ABN)
it can either be private or group
Commercial health plans
it covers the cost of health care services for the individual and/or family after the deductible and copays have been met
Insurance policies
the more freedom a plan offers…
the higher the pt responsibility will likely be
allows the patient to see providers within the network
no referrals required
more freedom to access the benefits
have coinsurance and deductible requirements
have a contracted group of providers
also called Fee-for-service (FFS)
monthly premium required
Preferred Provider Organization (PPO) plans
it also have a contracted groups of providers, but, pt must choose a pcp
Point-of-service (POS) plans
has a contract with a network pf providers for pt care
reimburse providers using a capitation method
no limit to the no. of times a pt may be seen
Health Maintenance Organization (HMO) plans
a government plan that was establish in 1965
largest health insurance program in the US
eligible for individuals 65 yrs old or older
Medicare
oversees the operations of Medicare
Centers for Medicare & Medicaid Services (CMS)
selected by CMS to process Part A, B, FFS claims, & DME
Medical Administrative Contractors (MAC)
composed of Medicare Advantage (MA) programs that allow all the same benefits as traditional Medicare and additional vision & dental services
Medicare Part C
it is a program to assist qualified individuals who have low income with premiums, deductibles, copays, and coinsurance
Dual eligibility
complete the parts of Medicare program from A-D
Part A - inpatient services
Part B - outpatient services
Part C - Medicare Advantage
Part D - Rx, Prescription
a government program that assists qualified individuals with health care needs
Medicaid
a supplemental policy to Medicare & offered by private insurance companies
help cover the costs of services that traditional Medicare doesn’t cover
Medigap
a government program for active military and their families
retirees and surviving spouses also qualify
TRICARE
