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Insurance > MRT 212 MIDTERM > Flashcards

MRT 212 MIDTERM Flashcards

1
Q

Reimbursement

A

compensation or repayment for healthcare services already rendered

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2
Q

Insurance

A

Reduction of a person’s (the insured party) risk of financial loss by having another party (insurer) assume the risk

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3
Q

Risk Pool

A

group of people who will be covered by a healthcare insurance plan

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4
Q

Deductible

A

Annual amount of money that the policyholder must incur and pay before the insurance will resume liability for the remaining charges or covered expenses

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5
Q

Copayment

A

Sharing measure in which the policyholder pays a fixed amount per service, supply or procedure that is owed to the healthcare facility by the patient. The fixed amount may vary by service type.

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6
Q

Premium

A

Amount of money the policy holder or certificate holder or subscriber must periodically pay a healthcare insurance plan in return for healthcare coverage

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7
Q

Guarantor

A

person who is responsible for paying the bill or guarantees payment for healthcare services.

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8
Q

UCR

A

usual, customary and reasonable

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9
Q

CPR

A

customary, prevailing and reasonable

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10
Q

Self-Insured plan

A

method of insurance in which the employer or other association itself administers the health insurance benefits for its employees or their dependents, thereby assuming the risks for the costs

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11
Q

Third party Payer

A

System whereby the insurance company or health agency (the payer-the 3rd party) pays the physician, or hospital, or other healthcare provider (aka provider—the 2nd party) for the covered care or services rendered to the patient (the 1st party).

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12
Q

Indemnity health insurance

A

traditional, fee for service healthcare plan in which the policyholder pays a monthly premium and a percentage of the usual, customary and reasonable healthcare costs. The patient can select the provider.

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13
Q

Characteristics of Reimbursement Methods

A

unit of payment, time orientation and degree of financial risk

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14
Q

unit of payment

A 
fee for service
independence/freedom
self-pay
fee schedule
more expensive/more services rendered
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15
Q

Episode of care

A

captitated payment
global payment
medicare home health
global surgical packages

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16
Q

Time orientation

A

retrospective
prospective
pre set payment example per diem payment

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17
Q

Degree of Financial Risk - patient

A 
Less Costly-less freedom of choice  
Prospective  
Capitated Payment   
Global Payment   
Per diem payment

More Costly-greater freedom of choice Fee for Service
Self-Pay
Retrospective

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18
Q

Degree of Financial Risk -provider

A

Lower reimbursement rates/guaranteed patient base Prospective
Capitated Payment
Global Payment
Per diem payment

Higher reimbursement/lower volume of patients Fee for Service
Self-Pay
Retrospective

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19
Q

Degree of Financial Risk-payer (insurer)

A 
Less financial risk   
Prospective
Capitated Payment   
Global Payment    
Per Diem
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20
Q

Importance of proper coding

A
  1. Communicates the services provided
  2. Stable and efficient payment process
  3. Compliance with guidelines and conventions
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21
Q

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

A

Protects employees who change jobs
Electronic transmission of medical records
Patient privacy

22
Q

Hospital inpatient procedure

Hospital outpatient procedure

A

ICD-10-PCS

HCPCS

23
Q

Physician in/out diagnoses

A

ICD-10-CM

24
Q

Facility hospital ambulatory in/out diagnoses

A

ICD-10-CM

25
Q

Health Care Procedure Coding System (HCPCS)

A

Coding system created and maintained by the Centers for Medicare and Medicaid Services (CMS) that provides codes for procedures, services, and supplies not represented by a CPT (Current Procedural Terminology Code)

26
Q

Level I

A

CPT codes. Copy written by the American Medical Association (AMA)

27
Q

Coding Compliance

A

Fraud-Intentionally making a claim for payment that one knows to be false

Abuse-unknowingly or unintentionally submitting inaccurate claims for payment

28
Q

False Claim Act

A

Civil War
1940’s
1980’s
Qui Tam-whistle blower lawsuit; person entitled to percentage of recovery

29
Q

Office of Inspector General (OIG)-Seven elements to ensure compliance (plan)

A
  1. Written policies and procedures
  2. Designation of a compliance officer
  3. Education and Training
  4. Communication
  5. Auditing and Monitoring
  6. Disciplinary action
  7. Corrective action
30
Q

CERT

A

The Centers for Medicare & Medicaid Services (CMS) calculates the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program.

31
Q

Recovery Audit Contractor (RAC)

A

Demonstration project required by the Medicare Modernization Act of 2003
Contracting with private business to combat Medicare fraud
Ensure correct payment for Medicare A and B claims

32
Q

Umbrella term

A

which includes private or commercial health insurance plans and Blue Cross Blue Shield plans
Usually associated with employment
Payments from voluntary health plans account for 33-35% of all healthcare expenditures in the U.S.

33
Q

Terms- Private

A

can mean commercial insurance (purchased); can denote insurance purchased by an individual versus an employer group

34
Q

Terms-indivdual

A

private healthcare plan; not large employer based

35
Q

Terms-group

A

employer based healthcare plan or group (i.e. association) based plan

36
Q

Terms-Maximum out of pocket:

A

specific amount, in a certain time frame, such as one year, beyond which all covered healthcare services for that policyholder or dependent are paid at 100% by the health insurance plan; also called catastrophic expense limit or stop-loss benefit

37
Q

Terms-formulary

A

list of preferred drugs; complying with formulary drugs will often reduce out of pocket expenses

38
Q

Assignment of benefits

A

Agreement between provider and payer in which provider directly bills the payer on behalf of the patient. The payer directly pays the provider the allowance. Denoted on UB form FL (box) 53 and CMS 1500 box 27

39
Q

Section of the plan

A

Definitions, eligibility and enrollment, benefits (maximum out of pocket expense), limitations, exclusions, procedure and appeals.

40
Q

Medicare

A 
1965 (implemented 1966)
*Age 65 or older
Eligible for Social Security or Railroad Retirement Benefits
Persons with permanent disability
End-stage renal disease
41
Q

Medicare A

A 
Part A: 
Hospitalization insurance•   
*Inpatient hospital•   
Long-term care•   
Skilled nursing services
Home health services•   
*Respite care•   
Hospice care-Beneficiary pays deductible and copayments after certain periods of time
42
Q

Medicare B

A 
Part B: 
Voluntary supplemental medical insurance
•  * Physician services
•   Medical services
•   Vaccines
•   Medical supplies–   *Beneficiary pays monthly premium plus annual deductible and copayments
43
Q

Part C: Medicare Advantage (MMA 2003)

A

Was Medicare+Choice (1997)
– HMO
– PSO
– PPO
– Beneficiary pays monthly premiums $50–$350
– Expanded scope of services (e.g., vision services)

44
Q

Part D: Medicare Drug Benefit

A

Implemented January 1, 2006
– Outpatient drug coverage provided by private prescription drug plans and Medicare Advantage
– Beneficiaries pay monthly premium, deductible, and copayments
– “Doughnut Hole

45
Q

Medicaid

A

Joint program between the State and the Federal governments Provider healthcare benefits to low-income persons and families

46
Q

Other Federal Plans

A 
PACE  
SCHIP  
Tricare 
-Prime (active duty)
-Standard
-Extra  
CHAMPVA (disabled or deceased) 
Indian Health Services
FECA
47
Q

Managed care plan

A

systematically merges clinical, financial, and administrative processes to manage access, cost, and quality of healthcare

Purpose of managed care is to provide affordable, high-quality healthcare

48
Q

Managed Care Organization (MCO)

A

Entity that integrates the financing and the delivery of specified healthcare services

49
Q

Benefits which must be offered in HMO plan (evidenced based)

A 
Physician services
Inpatient care
Preventive care and wellness
Prenatal care
Emergency services
Diagnostic and laboratory tests
Home health services
Access to mental and behavioral health and specialty care through referrals
50
Q

Characterizations of the MCO for Quality Care

A
  1. Selection criteria for providers
  2. Delivery of continuum of care to population including health and wellness management
  3. Care management tools
  4. Quality assessment and improvement
51
Q

Characterization of the MCO for Cost Effectiveness

A

Service management tools
Episode of care reimbursement
Financial incentives

52
Q

Types of MCO

A

HMO (health maintenance organization) Gatekeeper loser costs. referrals needed.
PPO more freedom higher cost combined HMO/PPO
EPO self funded
Medicare advantage

Insurance (2 decks)

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