Healthcare Financing and Reimbursement Flashcards
What has made it difficult for the average american to pay for their healthcare without insurance?
Rising costs
Why was private healthcare originally created?
To cover catastrophic injuries or impatient (hospital) admission.
How do insurance groups displace the risk of insuring an individual?
Through group cost sharing
What does HMO stand for?
Health Maintenance Organization
What are elements of an HMO?
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.
Define PPO.
Preferred Provider Organization
What are elements of a PPO?
Patients will be seen non preferred providers, but the cost share increases significantly for the patient.
What was social security created as?
“age entitlement”
What year did the social security act pass?
1935
What is the primary function of the social security act?
Provide monetary benefits to American citizens and legal residents 65 +, to reduce dependency on their families.
How is social security designed?
As a pay as you go system.
How is Social Security funded?
By payroll taxes from employees and employers
True or False, As long as the amount of contributions from workers exceeds those paid to beneficiaries the program can continue?
True
Who is eligible for Social Security?
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 are the amount of benefits determined for social security?
By calculating the average salary over 35 years
What does SSI stand for?
Supplemental Security Income
When was the SSI established?
1965 by title XVI of the social security act
What does SSI do?
It provides a minimum level of economic support for older adults.
What are the requirements to qualify for SSI?
Vert low income
How are SSI payments calculated?
Payments are calculated on the total monthly income with supplementation to the max allowed by state of residence.
When was Medicare enacted?
In 1965 XVII social security act
What is the purpose of Medicare?
To provide insurance coverage for elderly and disabled regardless of financial situations.
What is Medicare administered by?
The Centers of Medicare and Medicaid Services (CMS)
Who is eligible for Medicare?
Legally worked for 10 + years, be at least 65 yro, if younger than 65 must have severe disabilities. Coverage may be bought.
What does medicare cover?
Selected services, but they must be medically necessary
What is Medicare part A?
The hospital insurance plan
What does part A cover?
acute care, acute and short term rehab, some costs associated with hospital stays, home health under some circumstances.
What is the deductible for acute care days 1 - 60?
$1260
What is the copay for days 61 - 90?
$315 a day
How many “lifetime days” does an individual get?
60
What is the copay per lifetime day?
$630
True or False, Copays are repeated every time the person is readmitted to acute care facility with a few exceptions?
True
What % of the costs of the first 20 days in a skilled nursing facility for the purpose of rehab does medicare part A cover?
100%
What will medicare part A not cover for a skilled nursing facility?
When only assistance with personal care or medication supervision is needed.
What is Medicare part B?
It is purchased plan to cover some of the costs of services
What is the approximate cost of Medicare part B?
$104.90 per month.
What is the yearly deductible for Medicare part B?
$147
What doe Medicare part B cover?
Outpatient services like lab work, PT, OT, yearly physical and welcome to medicare physical within 12 months of the 65th birthday.
What is another name for Medicare part C?
Advantage
What does Medicare part C cover?
Covers services through a PPO or HMO. Provides extra benefits beyond those usually covered by part B.
What does Medicare part D cover?
Medications
All medicare part D plans have what?
An annual deductible and a certain amount of coverage until a cap occurs.
What is Medical?
Heather insurance for the low income, anyone who receives SSI and includes infants - elderly.
What does Medical do for older adults?
Helps them offset the high Medicare copays and deductibles.
What does medical cover.
More than Medicare, it includes custodial care, preventive care with no copays or deductibles.
Under Medi-Medi who covers hospital deductibles?
Medical
For Medi-Medi Medical pays for what?
Part B, Drug Plan, and LTC
What is the best plan for low income older adults?
Medi-Medi
Who is the largest healthcare payer in the United States?
CMS
True or false people can chose to purchase long term care insurance?
True
When is the best time to purchase LTC insurance?
Usually in 60’s
Define Revenue Cycle.
All administrative and clinical functions that contribute to the capture, management, and collection of patient services revenue.
What are the 5 basic components of the Revenue Cycle?
Intake, Utilization review, health information management and coding, billing and flames. collections.
Define intake in the revenue cycle.
patient registration, insurance identification, insurance verification
Define utilization review in the revenue cycle.
Pre-certification, pre-authorization, continued-stay reviews, appeals
Define health information management and coding in the revenue cycle.
documentation and coding
define billing and coding in the revenue cycle.
bill generation, claims submission, claims correspondence and inquires
Define collections in the revenue cycle.
Accounts receivable collections, payment posting/processing, denial management, collections correspondence and inquires
What is it called when a claim is submitted to payer for reimbursement for services rendered?
Billing
Why can claims be denied?
Incomplete information (missing data pieces)
Why can claims be rejected?
Due to coding errors, medical necessity issues, coverage or eligibility issues.
What is receiving and posting a payment called?
Collections
Define EBO
Explanation of benefits,the statement that covers the payment and shows amounts paid and explains things that are not paid or partially paid.
Define denial management.
Examining codes and remark codes to determine the reasons for claim denial.
Define DRG.
Diagnostic Related Groups
Define APC
Ambulatory Payment Organizations
What are prospective payment systems?
Payment amounts are determined in advance, maximums allowed are preset for services.
Define IPPS
Inpatient Prospective payment System
What is IPPS?
Reimbursement for impatient services determined prospectively based on diagnostic related groups, and their weights.
Define OPPS
Outpatient Prospective Payment System
What is OPPS.
Services have clinical resource utilization, payment is based on APC and its relative weight.
What is the future of RC?
Reimbursement based on outcomes, Accountable Care organizations.
