O&A Flashcards
Developing a Strategic Plan
- WOTS Up analysis
- weaknesses
- opportunities
- threats
- strengths
Three entities involved in determining an insurance program
subscriber, provider, insurance carrier
Subscriber
individual or group of individuals being insured
Probider
entity that is providing the service to the subscriber
Insurance carrier
entity responsible for setting fee structures with providers, paying bills for the subscriber, and determining the benefits to be paid
Insurance carrier
for profit entity, tries to reduce costs, answers to stockholders, negotiates fees for services, pays bills/ claims on behalf of pt/ subscriber for necessary care
Primary Care Physician
internal/family medicine physician, coordinates care for patients, gatekeeper to other health care providers
Gate Keeper
primary care physcian assigned by insurer to care for patient
Clain
demand made by insured for payment of benefits as provided by the policy
Copayment
predetermined, flat fee an individual pays for health-care services
Deductible
amount of lass that the insured pays before the insurance kicks in
Premium
price of insurance protection for a specified risk for a specified period of time
Medicare
FEDERAL FUNDED ppl 65+ ppl of any age w/ kidney failure/disease ppl who are permanently disabled Copay (80/20)
Medicaid
STATE AND FEDERAL FUNDED low income pregnant women children under 19 ppl 65+ the blind disabled nursing home care NO copay
4 Parts of Medicare
Part A (hospital insurance) Part B (Physician Insurance) Part C (Medicare advantage plan) Part D (Prescription Drug Coverage)
General Health Insurance
Coverage that covers an individual for illness, injury, hospitalization and emergency care
Accident Insurance (student athletes)
usually a low-cost insurance provided to students who participate in activities on school grounds or when engaged in school activities
Catastrophic Insurance
covers expenses when available funds from primary and secondary insurance carriers are exhausted
In-Network Benefits
services provided by preapproved providers for which the insurance company negotiates a fee for that service, cost savings due to lower fees from negotitaion
Out-of-Network Benefits
services that are provided outside of the eastablished network of providers, may prove costlier to subscriber, may not be an option w/in insurance plan
Excluded coverage
some services may be limited bc of pre-existing issue, insurance type, etc. military service injury, dental, massage, injuries sustained during suicidal act, international
Health Mainttenance Organization (HMO)
prepaid group insurance, preventative medicine, usually pays 100%
Preferred Provider Organization (PPO)
financial incentives to encourage policy holder to use approbed medical venders, have to pay fee
Exclusive Provider Organization (EPO)
type of PPO, services reimbursed only is pt uses contracted providers, will not pay “out-of-network”
Point of Service Plan (pos)
similar to PPO, assigns physician as gatekeeper, most ppo’s do not
Indemnity Plan
free to go to medical provider of choice, reimburses portion of cost covered services
Health Savings Account (HSA)
uniquely arranged from company to company, similar to PPO, funded by individuals or employer groups, HSA decides what types of coverage will be provided, negotiates with providers toward this end
Retiree Coverage
employer may provide health insurance after you retire, secondary payer, can cancel any time or reduce benefits, Medicare will become primary (>65)
Cost-Containment Considerations: Traditional
insurance company covers costs for athlete after pre-set deductible is paid, premium is experience related
Cost-containment Considerations: Aggregate
deductible applies to all athletes combined,similar to family deductible, money for deductable may be placed on an account and can roll over
Mandating Primary Insurance
increasing popularity
Problem: Some students do not have insurance, some insurances may not cover athlete at school
Adjusting PCP
change students PCP to campus physician making college in-network, some insurances allow exemptions
Reimbursement: Direct Compensation
payment comes directly from the individual receiving service, often for extra services not covered
Third-Party Reimbursement
compensated for a service from someone other than patient,typically insurance company
Obtaining Reimbursement from an Insurance company
must establish “medical necessity”
National Provider Identifier number to bill for services
At’s need to be physician extender or referral for at services
HCFA(CMS) 1500
Physician Visits
UB-92/HCFA(CMS) 1450
Hospital and facilities
CPT code
AT specific codes
CPT code 97005
Evaluation
CPT code 97006
Re-evaluation
Which budget category houses expensive, durable equipment w/ a 3yr+ lifespan
capital equipment
What state credentialing process protects the public and regulates specific professions by mandating duties that can and cannot be performed
Licensure
What legal defense claims the plaintiff understood activity hazards
Assumption of risk
What condition represents a violation in standard of care
breach of duty
What is the organization responsibilty delineation
chain of command
What type of negligence occurs when the plaintiff’s actions add to the injury, but the plaintiff mayh still be eligible for financial awards?
comparative negligence
What managed care program provides a set fee per member
capitation
What negligent tort exists when a person performs an intervention within the professional boundaries but does the intervention incorrectly
Misfeasance
What written statement defines an organization’s philosophy, purposes, and characteristics
mission statement
What federal act protects a patient’s medical records
health information portability and accountability act
What are the four types of managed health care organization
HMO, PPO,POS, and EPO
What federal act is infringed when a coworker makes an unwelcome sexual advance
Title VII of the civil rights act
Who is considered the “gatekeeper” of managed health care systems
PCP
What are CPT and ICD codes
reimbursement codes
What term identifies the amount that a family agrees to pay out-of-pocket for medical expenses before and insurer pays any part
deductible
What budget type requires allocation of funds for discrete activities
line-item budget
What reimbursement code do all health care workers use to describe the services provided
current procedural terminology codes
What reimbursement code do all health care workers use to describe the patient’s condition
international classification of disease codes
What reimbursement code do hospitals use to describe the services provided
universal billing codes
what is the level of medical sophistication and competency required of a person who performs a health care role
standard operating procedures
What is the length of time one has to file a claim against another
statute of limitations
What concise statement describes the ideal state of an organization
vision statemetn
What is the scientific study of human work
ergonomics
What term identifies the reasonable care used to avoid unreasonable risk
duty
To ensure safe operation and minimize the risk of patient injury, to what must whirlpool motors be connected
ground fault interrupter
Regarding athletic facilities, which of the following is outside the intended scope of practices of the athletic trainer
informing the coaching staff that the grass is too high
You are working at a hospital-based sports medicine clini. which of the following organizations would be most likely to visit your clinic during an on-site accreditation visit
the joint comission
which of the following statements correctly reflects currnet recommendations for the placement of electrical outlets in the treatment are of an athletic training room
electrical outlets should be placed at least 3ft from the ground and spced every 4ft through the facility
what type of insurance should athletic trainers maintain while practicing in the field
professional liability
