Practice/professional Issues Flashcards
Definition of Medicaid
An entitlement program initially established to provide medical assistance to low income individuals & families receiving public assistance or government welfare benefits.
Dual-eligible beneficiaries are Medicare recipients who also receive what?
Medicaid assistance for help paying Medicare premiums, & cost-sharing & covering key services, particularly in long-term care that Medicare excludes or limits.
What is the main funding source of long term care services?
Medicaid. Medicare & private insurance largely does not provide coverage for long term care. Medicaid finances 40% of all long term care spending, more than 60% of SNF pts are covered by Medicaid.
Who covers the cost of Medicaid?
The cost is shared by the federal government & the states. The government matches state Medicaid spending based on a formula that varies for each state, but federal match rate is at least 50%.
What services are exempt from cost-sharing?
Preventive services for children, emergency services, & family planning services.
Are there any penalties if the pt does not pay their cost-sharing amounts?
Yes, states can terminate Medicaid coverage of premiums are not paid & can permit providers to deny care in certain circumstances if Medicaid pts do not pay their cost-sharing amounts.
Medicare definition
Medicare provides health insurance for individuals over the age of 65, regardless of income or medical history. The program was expanded to include pts younger than 65 with certain medical conditions & disabilities.
What does Medicare Part A cover?
How is it funded?
Hospital insurance program- covers inpatient hospital services, skilled nursing facilities, home health & hospice.
Funded by a tax of 2.9% of earnings paid by employers & workers.
What does Medicare Part B cover?
How is it funded?
Supplemental medical insurance program- helps pay the outpatient, home health, & preventive services of the healthcare provider.
Funded by general revenues & beneficiary premiums.
What does Medicare Part C cover?
How is it funded?
Medicare advantage program- allows beneficiaries to enroll in a private plan, such as a health maintenance organization, preferred provider organization, or private fee-for-service plan, as an alternative to the traditional fee-for-service plan.
These plans receive payments from Medicare to provide Medicare-covered benefits, such as hospital & physician services.
What does Medicare Part D cover?
How is it funded?
Provides prescription drug benefits delivered through private plans that contract with Medicare.
A monthly premium is typically paid by beneficiaries who enroll in these plans.
Malpractice definition
The failure of a person with advanced education, to act in a reasonable & prudent manner.
What are the 4 elements of malpractice?
Duty of care
Breach of the standard of care
Injury
Proximal cause (i.e., that the injury was caused by the breach of standard of care)
What is the purpose of “incident-to” billing?
To allow a physician to bill for services provided by an assistant or delegate in the office. Ex- pt with HTN coming in for BP check. Pt is charged a level 1 visit.
