financials Flashcards
patient pays partial permiums to the employer
employer paid the full premium
organization make payment tot eh health care provider for medical services
patient also responsible for a small payment amount in the form of co pay to the provider
if patient goes outside network, their co pay is more
Health maintenance organization
exclusive provider organization
Reimbursement methodology 7 point service plan
preferred provider organization
types of HMO
most to least controlling
they took lower reimbursement to keep costs down
capitated
fee for service payment type
retrospective
perdiem
case rate
caitation
payment type
prospective
payer pays 80-90% of customary charges patient pays for the rest provider determines what is necessary no incentive to reduce servises liability concerns - no problem, just do more tests workers comp is this model
fee for service
patient paid all expenses of care sent forms to insurance company patient was reimbursed for expenses unrestricted choice of providers many could not afford the up front costs
old FFS/indemnity model
preferred providers in network with lower reimbursement
fees set on resource based relative value scale
basically a discounted FFS
medicare
preferred provider organization
looking for services that were not medically necessary
defined by insurer
cant return services so provider increases prices
utilization review
payments on a given time (per diem) or set of conditions (case rates)
per diem rates set using historical data. all services provided in a day are included
no incentive for patient to decrease costs
no incentive for provider to shorten stay
prospective payment systems
per diem, doesn’t matter what the ______ is
diagnosis
after the say, can still have retro UR
increases incentive to decrease stay
per diem + UR
single dollar payment for specific king of care
work well for diagnoses with expected interventions and outcomes
can help to standardize care, improve processes
case rates
case rate used by medicare
related to common diagnoses and procedure with fixed rates
higher weights are given to patients who are expected to require more care
still a flat per admission payment
diagnosis related group DRG
provider at risk for too many services and too long of a stay
payer risk minimized
can also lead to too much cost cutting
case rates and DRG
prospective payment system to try to control costs
transfers almost all financial risk to provider
if patients are healthy, provider wins
fallen out of favor because providers stopped accepting it a s a form of payment
payer risk minimized
provider assumes almost all of the risk
capitation
high deductibles
often have a tax advantage like a medical saving account or health savings account
modified catastrophic healthcare coverage
shift more risk to patient
patients become more active in healthcare
consumer directed health plans
from the affordable care act of 2010
reward providers that are able to manage chronic diseases for fairly large population
providers share in profit if they reduce costs
more financial risk to providers
accountable care organizations
compulsory hospital insurance plan for inpatient
part A medicare
covers hospitals, critical access hospitals and skilled nursing facilities for the first hundred days of dare
does not cover nursing care
what age do you qualify at?
medicare
65
people eligible for social security can get medicare after
24 mo
medicare: for home health, person must be
home bound
leaving home is taxing
medicare sets the price
hospitals must accept it
forced hospitals to look for efficiency
hve cut hospital length of stay dramatically
medicare part A: acute care hospitals
used in SNF
goal to reduce medicare payment
score based on ADLs and amount of services they need
Resource Utilization Groups RUGS
