Payment for OT Terms Flashcards
Beneficiary
A person receiving services.
Capitation
Payment system under which the provider is paid prospectively (on a monthly basis) a set fee for each health plan member regardless if no care is delivered.
Payment is typically determined in terms of “per member per month”.
Co-insurance
the monetary amount to be paid by a patient (usually expressed as a percentage of total charge).
Clinical/critical pathway
a standardized recommended intervention protocol for a specific diagnosis.
Deductible
the amount a patient must pay to provider before the insurance benefits will pay; usually expressed as an annual dollar amount.
Denial
the refusal by a payer to reimburse a provider for services rendered. Reasons for denial include benefits exhausted, duplication of services, and services not indicated.
Diagnosis code
A code that describes a patient’s medical reason or condition that requires health service.
Diagnostic related groups (DRGs)
the descriptive categories established by CMS that determine the level of payment at a per case rate.
Fee for service
the payment system under which the provider is paid the same type of rate per unit of service. Traditional, payer pays 80% and patient or provider is responsible for the remaining 20%.
Health insurance market
established by the ACA to allow consumers to compare the cost of insurance plans in their area.
Health Maintenance Organization (HMO)
the most common form of managed care. Maintains control over services by requiring enrollees to see only doctors within the HMO network and to obtain referrals before seeking specialty or ancillary care.
Managed care
a method of maintaining some control over costs and utilization of services while providing quality health care. Managed care organizations (MCOs) include HMOs and PPOs.
Per diem
a negotiated, per day fee for service. Typically used for inpatient hospital stays and skilled nursing facilities.
Preferred provider organization (PPO)
a form of managed care that is similar to an HMO but usually offers a greater choice of providers. As choices increase, percentage of payment decreases.
Private pay
individual receiving services pays
Procedure codes
does that describe specific services performed by health professionals
Prospective payment system (PPS)
the nationwide payment schedule that determines the medicare payment for each inpatient stay of a medicare beneficiary based on DRGs
Provider
entity responsible for delivery and quality of services. Providers bill insurance companies.
Third party payer
agencies and companies who are the primary reimburses for healthcare in the U.S.
Treatment authorization request (TAR)
THE MEDICAID FORM A PRIMARY CARE PROIVDER MUST COMPLETE TO DOCUMENT THE NEED FOR REQQUESTED MEDICALLY NECESSARY COVERED SERVICES AND THEIR SUPPORTING RATIONALE.
Usual and customary rate (UCR)
the average cost of specific health care procedures in a geographic area. This is the maximum amount the insurer will pay for a service and covered expense.
Reimbursement utilization group (RUGS)
Reimbursement for SNFs
One of 44 patient categories, each with a corresponding per diem reimbursement rate as mandated by Medicare.
