Heath care delivery models + Insurance fundamentals Flashcards
What is Accountable care organizations (ACOs)?
Accountable Care Organizations are groups of clinicians, hospitals and other health care providers who come together voluntarily to give coordinated high-quality care to their medicare patients.
What is Capitation?
Capitation is a fixed amount of money per patient per unit of time paid in advance to the physician for the delivery of health care services. The actual amount of money paid is determined by the ranges of services that are provided, the number of patients involved, and the period of time during which the services are provided.
What is Global budget?
This is a fixed total dollar amount paid annually for all care.
What is Health maintenance organization (HMO)?
They plan contracts with a medical center or group of providers to provide preventive and acute care for the insured person. HMOs generally require referrals to specialist, as well as pre-certification and preauthorization for hospital admissions, outpatients procedures, and treatment
What is Patient-center medical home (PCMH)?
In this care delivery model, a primary care provider (PCP) coordinates treatment to make sure patients receive the required care when and where they need it, and in a way they can understand
What is Pay for performance?
This reimbursement model compensates provider only if they meet certain measures for quality and efficiency.
What is Preferred provider organization (PPO)?
These plans have more flexibility than HMO plans. An insured person doesn’t need a PCP, but can go directly to a specialist without referrals.
What is Advance beneficiary notice (ABN)?
a form provided to the patient when the provider believes Medicare will probably not pay for services received
What is Allowed amount?
The maximum amount a third-party payer will pay for a particular procedure or service
What is Copayment?
an amount of money that is paid at the time of medical service
What is Coinsurance?
a policy provision frequently found in the medical insurance whereby the policyholder and the insurance company share the cost of covered losses in a specified ratio, such as 80:20
What is Deductible?
A specific amount of money a patient must pay out of pocket before the insurance carrier begins paying
What is Expiation of benefits?
a statement from the insurance carrier detailing what was paid, denied, or reduced in payment; also contains information about amounts applied to the deductible, coinsurance, and allowed amount
What is Participating provider (PAR)?
Providers who agree to write off the difference between the amount charged by the provider and the approved fee established buy the insurer
What is Medicare?
Medicare is federal health insurance for people 65 or older, some younger people with disabilities, people with End-Stage Renal Disease
