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
