Financing & Reimbursement Flashcards
What group came up with the idea of Dallas teachers paying $6.00 annual premiums to help reduce unpaid bills?
Blue Cross
What group was formed with physician support to help keep control between insurance companies and physician rates?
Blue Shield
What initiated the growth of private insurance in which companies began offering health benefits/fringe benefits?
1942 World War II Stabilization Act
- Tax deductible benefits for employers only
- large employee pools
What are HMOs and what do they focus on?
Health Maintenance Organizations
focus on preventative care
What rules were banned by the Department of Health and Human services in 1996 that obligates physicians not to discuss with patients modes of termination of pregnancy
Gag rules
What are PPOs?
Preferred Provider Organizations
What is the criteria for receiving Medicare?
Age over 65
Disabled- receiving social security
End Stage Renal disease
What does Part A of Medicare cover?
Hospital
SNF
Home Health Care
Hospice
What does Part B of Medicare cover?
Professional Services
Durable medical equipment
What does Part C of Medicare cover?
Medicare Choice Plans
Enhance Benefits
What does Part D of Medicare cover?
Prescriptions
What are DRGs?
Diagnosis Related Codes
for Medicare
“bundle” of services to treat a pt for a specific condition
Are DRGs weighted?
Yes, for hospital reimbursement
Example:
DRG 32- Concussion 0.5422
DRG 103- heart transplant 19.0098
What is the Resource Based Relative Scale used for and what is taken into account?
For physician reimbursement
- Physician work/skill
- Practice expense (geographically adjusted)
- Malpractice expense/liability
What is the Donut Hole and what does it mean for patients?
Medicare part D, Between 2700-6154 patients must pay 100% for their prescriptions. 25% of patients will stop taking meds when they reach this point
What is the reimbursement rate for PAs?
85% of physicians fee schedule
What must you apply for to be reimbursed for Medicare?
National Provider Identifier (NPI)
If a physician performs the first visit to a pt in a SNF, can a PA continually see that pt every 30 days?
No
I visit a month for 90 days
then 1 visit every 60 days
What is “incident to” billing
PAs 100% reimbursed
- physician sees new pt or for a new problem
- PA provides follow up for THAT condition
- physician is onsite
Net reimbursement of first assist for surgical PA
13.6%
Can you bill for a shared visit with a physician?
Yes, but not for procedures
What must the supervising physician sign
ER discharge
Outpt surgery discharge
Discharge summaries
Who is eligible for Medicaid?
Low income
Federal program
What level is Medicaid administered at?
State level
