Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Gero Final > Healthcare Financing and Reimbursement > Flashcards

Healthcare Financing and Reimbursement Flashcards

1
Q

What has made it difficult for the average american to pay for their healthcare without insurance?

A

Rising costs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Why was private healthcare originally created?

A

To cover catastrophic injuries or impatient (hospital) admission.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How do insurance groups displace the risk of insuring an individual?

A

Through group cost sharing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What does HMO stand for?

A

Health Maintenance Organization

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are elements of an HMO?

A

Case management and protective payment systems, primary care provider is the the gatekeeper of all services, must go to group providers only, co-pays to avoid moral hazard.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Define PPO.

A

Preferred Provider Organization

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are elements of a PPO?

A

Patients will be seen non preferred providers, but the cost share increases significantly for the patient.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What was social security created as?

A

“age entitlement”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What year did the social security act pass?

A

1935

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the primary function of the social security act?

A

Provide monetary benefits to American citizens and legal residents 65 +, to reduce dependency on their families.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How is social security designed?

A

As a pay as you go system.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How is Social Security funded?

A

By payroll taxes from employees and employers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

True or False, As long as the amount of contributions from workers exceeds those paid to beneficiaries the program can continue?

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Who is eligible for Social Security?

A

American Citizens, legal residents, 65 yro +, totally permanently disabled who have paid into the system for at least 10 years or married to someone that is eligible

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How are the amount of benefits determined for social security?

A

By calculating the average salary over 35 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What does SSI stand for?

A

Supplemental Security Income

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

When was the SSI established?

A

1965 by title XVI of the social security act

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What does SSI do?

A

It provides a minimum level of economic support for older adults.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the requirements to qualify for SSI?

A

Vert low income

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

How are SSI payments calculated?

A

Payments are calculated on the total monthly income with supplementation to the max allowed by state of residence.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

When was Medicare enacted?

A

In 1965 XVII social security act

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is the purpose of Medicare?

A

To provide insurance coverage for elderly and disabled regardless of financial situations.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is Medicare administered by?

A

The Centers of Medicare and Medicaid Services (CMS)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Who is eligible for Medicare?

A

Legally worked for 10 + years, be at least 65 yro, if younger than 65 must have severe disabilities. Coverage may be bought.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What does medicare cover?

A

Selected services, but they must be medically necessary

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What is Medicare part A?

A

The hospital insurance plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What does part A cover?

A

acute care, acute and short term rehab, some costs associated with hospital stays, home health under some circumstances.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is the deductible for acute care days 1 - 60?

A

$1260

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is the copay for days 61 - 90?

A

$315 a day

30
Q

How many “lifetime days” does an individual get?

A

60

31
Q

What is the copay per lifetime day?

A

$630

32
Q

True or False, Copays are repeated every time the person is readmitted to acute care facility with a few exceptions?

A

True

33
Q

What % of the costs of the first 20 days in a skilled nursing facility for the purpose of rehab does medicare part A cover?

A

100%

34
Q

What will medicare part A not cover for a skilled nursing facility?

A

When only assistance with personal care or medication supervision is needed.

35
Q

What is Medicare part B?

A

It is purchased plan to cover some of the costs of services

36
Q

What is the approximate cost of Medicare part B?

A

$104.90 per month.

37
Q

What is the yearly deductible for Medicare part B?

A

$147

38
Q

What doe Medicare part B cover?

A

Outpatient services like lab work, PT, OT, yearly physical and welcome to medicare physical within 12 months of the 65th birthday.

39
Q

What is another name for Medicare part C?

A

Advantage

40
Q

What does Medicare part C cover?

A

Covers services through a PPO or HMO. Provides extra benefits beyond those usually covered by part B.

41
Q

What does Medicare part D cover?

A

Medications

42
Q

All medicare part D plans have what?

A

An annual deductible and a certain amount of coverage until a cap occurs.

43
Q

What is Medical?

A

Heather insurance for the low income, anyone who receives SSI and includes infants - elderly.

44
Q

What does Medical do for older adults?

A

Helps them offset the high Medicare copays and deductibles.

45
Q

What does medical cover.

A

More than Medicare, it includes custodial care, preventive care with no copays or deductibles.

46
Q

Under Medi-Medi who covers hospital deductibles?

A

Medical

47
Q

For Medi-Medi Medical pays for what?

A

Part B, Drug Plan, and LTC

48
Q

What is the best plan for low income older adults?

A

Medi-Medi

49
Q

Who is the largest healthcare payer in the United States?

A

CMS

50
Q

True or false people can chose to purchase long term care insurance?

A

True

51
Q

When is the best time to purchase LTC insurance?

A

Usually in 60’s

52
Q

Define Revenue Cycle.

A

All administrative and clinical functions that contribute to the capture, management, and collection of patient services revenue.

53
Q

What are the 5 basic components of the Revenue Cycle?

A

Intake, Utilization review, health information management and coding, billing and flames. collections.

54
Q

Define intake in the revenue cycle.

A

patient registration, insurance identification, insurance verification

55
Q

Define utilization review in the revenue cycle.

A

Pre-certification, pre-authorization, continued-stay reviews, appeals

56
Q

Define health information management and coding in the revenue cycle.

A

documentation and coding

57
Q

define billing and coding in the revenue cycle.

A

bill generation, claims submission, claims correspondence and inquires

58
Q

Define collections in the revenue cycle.

A

Accounts receivable collections, payment posting/processing, denial management, collections correspondence and inquires

59
Q

What is it called when a claim is submitted to payer for reimbursement for services rendered?

A

Billing

60
Q

Why can claims be denied?

A

Incomplete information (missing data pieces)

61
Q

Why can claims be rejected?

A

Due to coding errors, medical necessity issues, coverage or eligibility issues.

62
Q

What is receiving and posting a payment called?

A

Collections

63
Q

Define EBO

A

Explanation of benefits,the statement that covers the payment and shows amounts paid and explains things that are not paid or partially paid.

64
Q

Define denial management.

A

Examining codes and remark codes to determine the reasons for claim denial.

65
Q

Define DRG.

A

Diagnostic Related Groups

66
Q

Define APC

A

Ambulatory Payment Organizations

67
Q

What are prospective payment systems?

A

Payment amounts are determined in advance, maximums allowed are preset for services.

68
Q

Define IPPS

A

Inpatient Prospective payment System

69
Q

What is IPPS?

A

Reimbursement for impatient services determined prospectively based on diagnostic related groups, and their weights.

70
Q

Define OPPS

A

Outpatient Prospective Payment System

71
Q

What is OPPS.

A

Services have clinical resource utilization, payment is based on APC and its relative weight.

72
Q

What is the future of RC?

A

Reimbursement based on outcomes, Accountable Care organizations.

Gero Final (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions