financials

Question 1

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

Answer 1

Health maintenance organization

Question 2

exclusive provider organization
Reimbursement methodology 7 point service plan
preferred provider organization

Answer 2

types of HMO

most to least controlling

Question 3

they took lower reimbursement to keep costs down

Answer 3

capitated

Question 4

fee for service payment type

Answer 4

retrospective

Question 5

perdiem
case rate
caitation
payment type

Answer 5

prospective

Question 6

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

Answer 6

fee for service

Question 7

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

Answer 7

old FFS/indemnity model

Question 8

preferred providers in network with lower reimbursement
fees set on resource based relative value scale
basically a discounted FFS
medicare

Answer 8

preferred provider organization

Question 9

looking for services that were not medically necessary
defined by insurer
cant return services so provider increases prices

Answer 9

utilization review

Question 10

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

Answer 10

prospective payment systems

Question 11

per diem, doesn’t matter what the ______ is

Answer 11

diagnosis

Question 12

after the say, can still have retro UR

increases incentive to decrease stay

Answer 12

per diem + UR

Question 13

single dollar payment for specific king of care
work well for diagnoses with expected interventions and outcomes
can help to standardize care, improve processes

Answer 13

case rates

Question 14

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

Answer 14

diagnosis related group DRG

Question 15

provider at risk for too many services and too long of a stay
payer risk minimized
can also lead to too much cost cutting

Answer 15

case rates and DRG

Question 16

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

Answer 16

capitation

Question 17

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

Answer 17

consumer directed health plans

Question 18

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

Answer 18

accountable care organizations

Question 19

compulsory hospital insurance plan for inpatient

Answer 19

part A medicare

Question 20

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?

Answer 20

medicare

65

Question 21

people eligible for social security can get medicare after

Answer 21

24 mo

Question 22

medicare: for home health, person must be

Answer 22

home bound

leaving home is taxing

Question 23

medicare sets the price
hospitals must accept it
forced hospitals to look for efficiency
hve cut hospital length of stay dramatically

Answer 23

medicare part A: acute care hospitals

Question 24

used in SNF
goal to reduce medicare payment
score based on ADLs and amount of services they need

Answer 24

Resource Utilization Groups RUGS

Question 25

government voluntary program
financed by premiums paid by patients
covers doctors services, outpatieent hospital care, outpatient rehab, durable medical equipment, medical supplies
premium around 100 per mo

Answer 25

medicare partB

Question 26

jointly funded by federal and states but administered by states
goal to provide healthcare for the poor
provides minimally necessary or minimally available healthcare
for low income families with children, individuals receiving social security income, pregnant women with incomes less than a specified percentage of the federal poverty level

Answer 26

medicaid