FINANCIAL MANAGEMENT Flashcards
traditional indemnity insurance policies
coverage on a fee-for-service basis, in this method of reimbursement, the insurer pays the provider a fee based on the cost of service
employer-sponsored plans
offer group coverage, while individuals who buy insurance on their own receive individual coverage (which may extend to family members as well). The patient is usually responsibe for paying a deductible and a coinsurance amount.
basic insurance
covers a specific dollar amount for physicians’ fees, hospital care, surgery, and anesthesia
major medical insurance
covers some of the costs of catastrophic expenses from illness or injury
traditional insurance
Blue Cross/Blue Shield indemnity policies
Blue Cross
covers hospitalization, radiology, and other basic coverage under the health plan
Blue Shield
covers the major medical portion and physician fees
capitated plan
a managed care group makes a fixed per capita payment periodically to a medical service provider (such as a physician) in return for medical care provided to enrolled individuals
MCO
managed care organizations
managed care system
the insurers require that policyholders seek medical attention only from preferred providers
preferred providers
physicians and other health care professions who contract with the insurance carrier to provide patient care at a discounted rate
HMO
health maintenance organizations
6 primary MCO models
- integrated delivery systems
- health maintenance organizations
- exclusive provider organizations
- preferred provider organizations
- physician-hospital organization
- utilization review organizations
integrated delivery systems
groups of affiliated provider sites that operate under single ownership to offer full and/or specialty services to the subscribers
HMO’s
health maintenance organization
cover large groups of people for a monthly premium and a small copayment from the patient each time of service
closed-panel HMO
when the HMO employs the physicians
open-panel HMO
establish a network of preferred providers who agree to a capitated contract fee schedule
EPO
exclusive provider organization
plan delivers in-network-only benefits through the national Blue Card PPO network
PPO
preferred provider organization
a network of physicians and hospitals that have contacted together with insurance companies to provide health care at a discounted fee
PHO
physician-hospital organization
a hospital and selected physicians may form a business arrangement
utilization review organizations
also known as third-party administrators, that supervise funds set aside to cover medical expenses to employees under self-insured plans
Medicare program
the federal government funds the health insurance coverage for the aged and disabled in the United States and was initiated by an act of Congress in 1965
CMS
Centers for Medicare and Medicaid Services
Medicare coverage Part A
covers hospital care, skilled nursing home care, and home health care
Medicare coverage Part B
covers outpatient care, physician services, certain home health services, durable medical equipment, and some health services not covered under Part A
AGI
adjusted gross income
UCR
usual, customary, and reasonable
“usual”
refers to the fee that the specific physician charges most of his patients for the same treatment
“customary”
based on the average charge for a specific procedure by all the physicians practicing the same specialty in a specific geographical location
“reasonable”
refers to the midrange of fees charged for this type of procedure or visit
Medicaid program
another form of government-funded health insurance for people who are unable to work due to illness or life circumstances, that is funded by both the federal and state government. Eligibility for coverage is based on income, employment status, and state-specific requirements
TRICARE
covers dependents of active-duty personnel, retired personnel, and dependents of personnel who died on active duty
CHAMPVA
The Civilian Health and Medical Program of the Department of Vertans Affairs
covers spouses and unmarried dependent children of verans with permanent total disabilities from service-related injuries and the surviving spouses and children of veterans who died of service-related disabilities.
catchment
military dependents are eligible to receive care within a 40-mile radius from a military base
workers’ compensation
when an on-the-job accident or illness results in injury and/or disability, workers’ compensation insurance pays the medical bills and a significant portion of the lost wages if the patient was covered by a workers’ compensation policy
self-insured plans
special accounts are established and rather than paying premiums to an insurance carrier, the entity makes payments into the plan
RVUs
relative value units
identify a range of charges for varying degrees of common office procedures and activities
RBRVs
resource based relative value scale
these scales help rank a variety of laboratory tests and medical products relative to the intensity of labor and goods used to produce them
DRGs
diagnostic-related groups
in this system, the government, under the Medicare program, pays a flat fee to the hospital based on a patient’s diagnosis, age, and presence of comorbidities. Payment is then made to the hospital, regardless of the actual costs incurred in the episode of illness
bookkeeping
the actual daily recording of the accounts or transactions of the business
accounts receivable
the money owed to the office by third-party payers or patients
accounts payable
amounts of money due for goods and services provided to the practice office
(ex. payroll, rent, utilities, housekeeping)
adjustments
entries made to change the patient’s balance, but they do not represent charges or payments
The Truth-in-Lending Act (Consumer Credit Protection Act of 1968)
was established to protect consumers by requiring that providers of installment credit state the charges clearly in writing and express the interest as an annual rate
monthly billing
all accounts are billed at the same time each month
cycle billing
all accounts are divided alphabetically into groups, with each group billed at a different time
coding
the process of converting descriptions of diseases, injuries, and procedures into numerical designations
CPT
Current Procedural Terminology
AMA
American Medical Association
WHO
World Health Organization
episode of care
care for a certain condition or care over a specified time period
The Affordable Care Act
designed to reform the health care system by providing affordable insurance coverage and access to quality health care for all Americans while curbing or controlling the cost of health care spending; designed to eliminate discrimination in delivering services and charging for those services
