Mod 10: Payment Basics Flashcards
one who purchases an insurance policy
subscriber
DME
durable medical equipment
-prescribed by provider
insurance cost that’s out of pocket
(insurance) premiums
money that subscriber pays before insurance pays for cost of covered services
deductible
flat fee paid for specific services
co-payment
cost-sharing obligation (%) under health insurance policy
co-insurance
bill submitted by HC provider for payment/reimbursement of services
claims
insurance source: individual purchases directly from company
private non-group insurance
insurance source: offered as benefit to employee & employer/ee pays cost
group insurance/employer-sponsored health insurance
insurance source: federal and state funded programs
government insurance
(Medicare/aid)
insurer pays cash
uninsured/self-pay
insurance type: economic hazard insurance controlled/paid by govt. programs
social insurance
-w/ eligibility requirements
insurance type: plan implemented by managed care organizations w/ PPS and provider network
managed care
managed care: pt. choose PCP who acts as gatekeeper for all HC services (restrictive)
Health Maintenance Organization (HMO)
managed care: open managed care model
Preferred Provider Organization (PPO)
managed care: subscribers select type of HC provider when needed (higher cost, more choices)
Point of Service (POS)
insurance type: protects individuals/companies that are responsible for another’s injury
casualty insurance (ex: worker’s comp)
insurance type: reimburses pt. for out-of-pocket medical expenses that are covered by an ins. policy; doctor submits claim for reimbursement
indemnity insurance
insurance type: pt. pays bill in full each time service provided
cash-based payment (not insurance)
uniformed services health care program that now allows PTAs/COTAs to be authorized providers
Tricare
Medicare ___: hospital insurance w/ inpatient admission requirements (100% coverage 1st 20 days)
Medicare Part A
Medicare ___: supplemental medical insurance (SMI), mostly outpatient, preventative and DME
Medicare Part B
Medicare ___ : Medicare Advantage; private insurance plans
Medicare Part C
Medicare ___: optional; subsidizes cost of prescription drugs
Medicare Part D
Children’s Health Insurance Program (CHIP) covers who?
uninsured children & pregnant women
Medicare Administrative Contractors (MACs)
contract w/ private insurance companies;
determined by geographic region
Medicare part A/B
MCOs
Managed Care Organizations- implement managed care plans
-negotiate contracts w/ providers
-restrict access to care to manage cost
Are services provided by PTA reimbursible under Medicare Part A?
Yes
