Managed Care Payment Methods Flashcards
Capitation
A payment system in which health care providers (physicians, hospitals, pharmacists, etc.) receive a fixed payment per member per month (or year), regardless of how many or few services the patient uses.
Coinsurance
An insurance policy provision under which both the insured person and the insurer share the covered charges in a specified ratio
Co-payment
A cost-sharing arrangement in which the managed care enrollee pays a specified flat amount for a specific service (such as $2.00 for an office visit or $1.00 for each prescription drug)
Deductible
Amounts required to be paid by the insured under a health insurance contract before benefits become payable.
Discounted Fee-for-Service
An agreed-upon rate for service between the provider and payer that is usually less than the provider’s full fee.
Fee for Service
A method of reimbursement based on payment for services rendered. Payment may be made by an insurance company, the patient, or a government program, such as Medicare or Medicaid.
Out of pocket expense
The amount not reimbursed by insurance coverage and paid by the patient such as co-payments, deductibles and premiums.
Pharmacy benefit coverage
Coverageof prescription drugs by an insurance company.
Premium
he amount paid to an insurer for providing coverage, typically paid on a periodic basis (monthly, quarterly, etc.).
Prevailing charge
This is a fee based on the customary charges for covered medical insurance services.
Reasonable Charge
A methodology used by Medicare to determine reimbursement for items or services not yet covered under any fee schedule.
Reasonable Cost
A methodology used by Medicare to determine reimbursement for items and services that takes into account both direct and indirect costs of providers such as hospitals, as well as certain Medicare HMOs and competitive Medical Plans.
Reimbursement
Refers to the actual payments received by providers or patients for benefits covered under an insurance plan.
Third-Party Payment
Payment by a financial agent such as an HMO, insurance company, or government rather than direct payment by the patient for medical-care services
Usual, Customary, and Reasonable (UCR) Charges
In private health insurance, the basis for reasonable-charge reimbursement of physicians.
“Usual” refers to the individual physician’s fee profile, equivalent to Medicare’s “Customary” charge screen.
“Customary,” in this context, refers to a percentile of the pattern of charges made by physicians in a given locality.
“Reasonable” is the lesser of the usual or customary screens.
