In-Class Quiz Review Flashcards
what is a copayment
set amount
A fixed amount paid by a patient for a specific medical service, usually at the time of the service. For example, a person might pay a $20 copayment for a doctor’s visit, with the remaining cost covered by insurance.
what is coinsurance
a percentage of the allowed amount
A percentage of the cost of a covered healthcare service that the patient is responsible for paying after the deductible has been met. For instance, if the coinsurance is 20%, the insurance covers 80% of the cost, and the patient pays the remaining 20%.
what is a deductible
amount you pay before insurance will pay anything
The amount a patient must pay out-of-pocket for covered healthcare services before the insurance plan begins to pay. For example, if a deductible is $1,000, the patient must pay $1,000 before insurance starts covering expenses.
what is prospective payment
A method of reimbursement in which healthcare providers are paid a predetermined, fixed amount for each case or patient, regardless of the actual cost of care. This is commonly used in systems like Medicare’s Diagnosis-Related Groups (DRGs).
the hospital already knows how much they are going to get per patient based on DRG
look at each indiv diagnosis and what resources are needed to provide a good outcome for that diagnosis
how many visits, how many procedures, what procedures, what meds, IVs, supplies, nurses, etc.
then look at all the diagnosis and group it based on the resources they need
diagnostic related groups - related because they use the same amounts and types of resources
what are captivated costs
set amount to care for a set number of people for a set period of time
(likely intended to be Capitated Costs): A payment arrangement where a healthcare provider is paid a set amount per patient per period (e.g., per month) regardless of the number or type of services provided. This is often used in managed care systems to control healthcare costs.
what is moral hazard
The concept that individuals may take more risks or use more healthcare services when they are protected from the full cost of those services, such as when they have insurance coverage. It highlights the potential for increased utilization due to reduced personal financial responsibility.
if you have coverage you dont care what it costs youll just go and go as much as you want and dr treats without concern for cost because of guaranteed source of payment
what are the 3 pillars of healthcare
access
quality
cost
What is the concept of insurance?
Risk
Pulling - multiple members put into towards their health insurance
Those with greater health have less risk and are paying into the insurance
We want to have more healthy people = more money
This leads to being more likely to cover everyone who is sick
If everyone is sick it won’t work as well
what is the hill-burtons act
passed in 1946 by congres and made direct government grants for communities to build hospitals, leading to increase in access to care and hospital beds
contracted rate
allowed amount
what the insurance will pay the physician for the service
Moral Hazard
Moral hazard refers to a situation in which an individual or organization is more likely to take risks because they do not bear the full consequences of their actions. This typically occurs when one party in a transaction is shielded from risk, leading to potentially careless or irresponsible behavior.
