Primer 25 -Healthcare System

Question 1

What is Co-pay?

Answer 1

The amount the insured person says at the time of service (e.g., $30 for a clinic visit or $15 for a particular drug). This may be on top of a Premium.

Question 2

What is a Deductible?

Answer 2

The amount an insured person must pay “out-of-pocket” before the health insurance begins to pay.

Question 3

What is a pre-existing condition?

Answer 3

A condition that a patient is known to have that is not covered by health insurance.

Question 4

What is a Lifetime maximum?

Answer 4

The maximum amount that an insurance company agrees to pay, as specified in the plan that is purchased.

Question 5

What is a Network (in healthcare system)?

Answer 5

The group of healthcare providers that has agreed to a reduced payment in oder to have access to a larger number of patients.

Question 6

What is a Major medical?

Answer 6

High deductible plan that covers the patient in the event of excessive medical expenses.

Question 7

What does HMO stand for?

Answer 7

Health Maintenance Organization.

Question 8

What does PPO stand for?

Answer 8

Preferred Provider Organization.

Question 9

What is the difference between HMO and PPO?

Answer 9

HMO: Primary care physician (PCP) is the gatekeeper to more specialized care. In order for medical expenses to be covered, the provider has to be “in-network” medical care.
PPO: There is no gatekeeper to the specialist. Patients can see whomever they want; however, the cost is higher for “out-of-network” medical care.

Question 10

What a Minor emergency clinic?

Answer 10

Heavily utilized by patients w/o any third party coverage. Usually offers no primary or secondary prevention.

Question 11

What is a Cash-only clinic?

Answer 11

Physician refuses to take any third-party payment, essentially returning back to the old patient-physician system. Patients may or may not carry additional “major-medical only” coverage.

Question 12

What is a Sliding scale clinic?

Answer 12

A patient pays a nominal fee based on income. This is usually run by a charity with a volunteer physician in order to minimize costs.

Question 13

What is Concierge medicine?

Answer 13

Physician charges an annual fee for a specifically designated set of services (eg., unlimited visits or 4 visits a year).

Question 14

What is Boutique medicine?

Answer 14

Physician offers unique services not covered by insurance but desire by affluent patients (usually cosmetic in nature) in order to increase clinic revenue (eg., Botox injections).

Question 15

What is Group physician networks?

Answer 15

In an effort to exclude third-party systems, and regain control of their own payments, physician groups join clinics together, build their own hospitals, and run their own

Question 16

What is a Premium?

Answer 16

The amount the insured person has to pay the insurance company (usually paid monthly).

Question 17

What is a Formulary?

Answer 17

The medication for which insurance companies will pay. Generics are preferred.

Question 18

What is Utilization Management?

Answer 18

Evaluation of the appropriateness, necessity, and efficiency of health care services.

Question 19

What is Resource-Based Relative Value Scale?

Answer 19

A scale that determines what a physician should be paid for a procedure (CPT code) or service in a specific region of the country, based on physician work, regional practice expense, and regional malpractice expenses.

Question 20

What does MCO stand for and what does it do?

Answer 20

It is Management Care Organizations. They are organizations that attempts to maximize quality of care and minimize the cost of care. They use techniques such as encouraging patients and physicians to choose less costly care, controlling inpatient admissions and lengths of stay and emphasizing preventive medicine. Accomplished thru a designated utilization management person or department.

Question 21

What demographic is accepted to Medicare?

Answer 21

The Elderly (medicarE. E for elderly).

Question 22

What demographic can apply for Medicaid?

Answer 22

The poor and disabled. (medicaiD for destitute and disabled).

Question 23

What is CHIP?

Answer 23

Children’s Health Insurance Plan.

Question 24

What is Fee-for-Service?

Answer 24

Payment is provided for a specified service; payed a certain amount for runny nose and higher amount for patient with mutliple complicated problems.

Question 25

What is Capitation?

Answer 25

The physician receives a fixed payment for a period of time or number of patients (ER shift/Minor emergency shift, Concierge practice, HMO).

Question 26

What is Salary?

Answer 26

The physician is payed a specified amount, regardless of work performed; universities, hospital administration, base salaries.

Question 27

What is Pay for performance?

Answer 27

Payment is increased if a physician meets pre-established targets; increased pay by the health care organization for meeting certain criteria such as preventative medicine targets (vaccines, colonoscopy, and HgbAIc).

Question 28

What is Nonpayment for performance?

Answer 28

No payment is made for a complication that could have been avoided; a funding entity may agree NOT to pay a physician for complications such as leaving a catheter in place, nosocomial infections, and surgical site infections.

Question 29

What are “young invincibles”?

Answer 29

These are people (usually under 30) that tent to not have many health problems and tend not to purchase insurance. In order for a third-party payer to afford to care for an ailing patient at a low premium cost to that patient, healthy patients must be present in the system to bear the burden of the additional expenses.

Question 30

What is freedom of choice?

Answer 30

Patients that need others to carry the burden of their healthcare expenses are at odds with those that want to be free to not have to carry that burden. The US government would like everyone to carry the burden via the “Individual Mandate” in the PPACA. Others argue that this violates their freedom.

Question 31

What is Excessive complexity?

Answer 31

All complexity of the healthcare system leaves patient at a loss to understand where to go for healthcare. Additionally, this complexity requires hiring individuals to manage the complexity which drives up the cost of healthcare.

Question 32

Which usually offers patients a greater variety of physicians to choose from: HMO or PPO?

Answer 32

PPO.

Question 33

What is the difference between being paid by capitation and free-for-service?

Answer 33

Fee-for-service is payment provided for a specific service while capitation is fixed payment for a period of time or number of patients.

Question 34

What must a hospital submit to a third-party payer in order to receive payment for services?

Answer 34

Submit ICD-9 diagnosis codes and CPT service/procedure codes.

Question 35

What department in a hospital oversees the maximization of the quality of care while minimizing the cost of care?

Answer 35

Utilization Management department (Utilization review).