Quiz 1 Flashcards
1
Q
Any profit generated from the enterprise can be paid to shareholders (owners)
they do pay property & sales taxes
A
for proffit
2
Q
Any profit generated from the enterprise is put back into the business NO shareholders (owners) Do NOT pay property & sales taxes
A
not for proffit
3
Q
The amount the patient must pay before the insurer will pay anything
A
deductible
4
Q
Amount patient pays at time of service ALL YEAR (even after deductible is met
A
copay
5
Q
A percentage of the total cost that the patient must pay
Usually ranges from 10-20% for in-network services
A
co insurance
6
Q
public insurance is aka
A
govt insurance
7
Q
sometimes still called “indemnity”
Provider billed insurer and insurer paid the claim
A
fee for service
old way of insurance
8
Q
the dominant pay sx until the 1990s
A
FFS
9
Q
A method of reimbursement based on payment for services rendered. Payment made by an insurance company, the patient, or a government program, such as Medicare or Medicaid. With respect to the physicians or other suppliers of service, this refers to payment in specific amounts for specific services rendered. In relation to the patient, it refers to payment in specific amounts for specific services received, in contrast to the advance payment of an insurance premium or membership fee for coverage, through which the services or payment to the supplier are provide
A
FFS
10
Q
2 types of managed care
A
HMO
PPO
11
Q
type of managed care that were successful in reducing healthcare inflation for the first time in American history
A
HMO
12
Q
A form of “managed care”
started in 1980’s
providers sign contracts governing payment
Insurers offer lower premiums by restricting the provider panel (or # of in network docs) but not the most restrictive form of managed care
A
PPO - preferred provider organization
in network/out of network = PPO
13
Q
type of managed care New idea = cost responsibility by PCP’s through capitation Gained popularity in 1990’s for: Reduced premium costs Reduced health care cost
A
HMO
health maintanance org
14
Q
why were HMOs unpopular in the 90s
A
loss of pt choice
15
Q
type of coverage that was usually a combination of a Medical Savings Account (MSA) and a high deductible health plan
New idea = cost responsibility borne by the patient
A
consumer directed health plan
CDHP
16
Q
what the provider submits to the insurer
A
claim
17
Q
EOB
A
Explanation of Benefits
defines the allowable = what the insurer will pay
Is the definitive document of what the provider will be paid by insurer & patient
Example of an EOB for a $49,000 outpatient procedure
18
Q
The amount the insurer will actually pay
Will be defined on the EOB
A
allowable
19
Q
what is this:
Your contract calls for you to be paid $80 per outpatient PT visit
$80 is the ______
Even if the visit lasts one hour and you bill $500, you will be paid $80
A
allowable
20
Q
FEDERAL insurance benefit plan for ALL elderly (65+ years old)
Uniform benefits across all states
A
medicare
21
Q
medicare is regulated by
A
HHS (health and human services)
22
Q
medicare was passed and implemented what years
A
Passed in 1965 and began in 1966
23
Q
what is MRP
A
Medicare Replacement Plans
“Medicare Managed Care”
Patients can opt out of traditional Medicare and be covered by a private insurer (e.g., Humana, United Healthcare, etc.)
Medicare pays the patient’s premium
24
Q
eligibility for medicaid varies by __
A
state (administered by the state)
25
medicaid is funded how
fed AND state
26
Billing system using procedure codes (defacto billing standard in the USA)
CPT4
| current procedural terminology
27
CPT 4 was created by what org
Developed and owned by the American Medical Association (AMA)
28
What is ICD 9
International Classification of Diagnoses – Version 9
| Diagnostic coding system used by most countries to classify patient diagnoses
29
what does PPS stand for
prospective payment sx
30
what is PPS
Adopted by Medicare with TEFRA in 1983 with DRG’s then with BBA 1997
Payment system whereby the payor knows what will be paid AHEAD OF TIME (prospectively) for diagnoses or procedures
31
first medicare form of PPS
DRG
32
Hospital is paid one lump sum for the entire length of stay is a CASE RATE or
no more charging for every individual service
DRG
| dx related group
33
specifics of an IRF
3+ hours of PT, OT, SLP per day
| Minimum of 5 days of therapy per week
34
how many hrs of therapy per day for SNF
less than 3
35
HHA
home health agency
36
2 types of risk
demand
| volume (utilization)
37
what is demand risk
number of pple
The more people that seek (demand) a service the more the insurer (and/or patients) will have to pay
If more people seek the service the risk (cost) increases
If fewer people seek the service the risk (cost) decreases
38
volume (utilization risk) has to do with what 3 things
Type services are performed
Quantity of services performed
Length of time services are performed
39
OOP goes towards
the deductible
40
how did FFS have no incentives for quality
Mistakes were paid for
Do more = get paid more = long LOS
Don’t get paid more for doing higher quality work
“Blank Check Syndrome”- if pt doesn’t have to pay for it, it’s free for all for whatever is performed by HCP
Risk Profile=Insurer bears it all, demand & volume
Provider has none
41
difference btwn FFS and discounted FFS
Fee for service you could go anywhere
Discounted fee for service = you trade discount for volume (provider decreases charge and gives a % discount, and insurance companies will put them in a preferred group) (but bc you gave discount of overall visit, increase in ind prices of interventions occurred)
42
who assumes risk for DFFS
Insurer still bears all demand and volume risk
43
what is the dominant form of payment for OP services in KC
fee schedule
44
Negotiating a price per code (cpt) – these vary btwn clinics (based on insurance preference list if you agree to do discounted fee for service)
fee schedule
45
Form of payment whereby the insurer pays on a per CPT code basis, but the amount paid is a pre-negotiated amount that is NOT based on charges
No matter what you charge, you will only be paid what the prenegotiated amt is.
The dollar amount is the final result of your negotiations with the insurer
fee schedule
46
MPFS
medicare physician fee schedule (type of fee schedule)
47
why do fee schedules have no incentive for quality
providers would do certain interventions tied to certain codes and avoid those that didn't pay well
48
with fee schedule, pricing is ____
irrelevant
49
Ex of downfall of ______: 8$ for US and 60$ for Manual, most private PTs won’t do the cheaper interventions
The pricing is irrelevant plays into PT clinics that have multiple locations vs the 1 stand alone PT clinic.
fee schedule
50
who assumes risk in fee schedule
Insurer still bears all demand and volume risk
Provider begins to bear some volume risk if the fee schedule amounts are low such that they do not cover the per visit costs of providing care
51
per diem applies to per __ or per __
day
| visit
52
ONE $$$ Payment for Entire LOS
No matter how many procedures/surgeries/interventions
No matter how long the LOS was
No matter how ill the patient is
case rate
53
whats the incentive with case rate
Very efficient care reduce LOS
If LOS is too long then will lose money
If do unnecessary procedures then will lose money
54
per diem vs case rate
case rate= the Sooner you get them out of hosp, the more money is made by hosp
In perdiem, the longer you keep them the more money you make
55
explain risk involved in case rate
Insurer bears ONLY demand risk
Insurer pays providers only when people seek out the service, but that payment will be the same no matter what
```
*Provider now bears ALL volume risk
Is on the hook for:
Type of services provided
Quantity of services provided
Duration (LOS) that services are provided
```
56
A form of case rate, different payment levels depending on the dx
you must do coding accurately
DRG
57
How medicare pays acute hospitals for all stays
drg
58
ONE $$$ Payment for Entire LOS
Still not sensitive to any volume considerations
BUT
Is sensitive to diagnostic group that patient falls into
DRG
59
what is the 200 with DRG
~200 “transfer” MS-DRGs mitigate Medicare’s risk- ex: allotment for THA is 5 days, but if you get them out of the acute hosp before the allotted DRG, they only pay for the days they were there (not the total allotted DRG). The 200 are the most common procedures in the US
60
with capitation, payment has zero to do with ___
LOS
61
with this plan you get paid a flat rate per member per month (PMPM) This plan, you get paid regarless if 8000 or 0 pts show up in your clinic for that month
capitation
62
ex of capitation, how much is paid
Ex: 8,000 covered lives in their plan at 5$
8,000 X $5 PMPM
$40,000 payment per month made to PCP, regardless if you see pts or not
63
with capitation you get paid more to do
less
64
explain who has risk with capitation
Insurer bears essentially none for PCP services
Provider has essentially become the insurer
*Bears demand and volume risk for those services
65
differentiate btwn capitation and global capitation
with capitation, docs were paid more to not see pts
Capitation - PMPM (month)
With reg capitation, docs would refer to specialists to keep them out of their office.
With global, Doc is only capitated under one practice within the group, insurance companies pay 1 flat rate for the group of pts for the entire YEAR, if you refer them out to someone else you get sent the bill (can’t use referral to offload cost).
66
incentives with global capitation
Prevention = manage health of members on own
YOU Monitor chronic issues
Diabetes, COPD, CHF, etc.
Cost effectively manage acute problems
67
who assumes risk with global capitation
The Practice is essentially the insurer
Insurer is simply is a premium pass-through
Provider/practice Bears ALL demand and volume risk (for ALL services
68
PCMH
pt centered medical home
one conglomerate of HCP under the same practice
could use global capitation
manage the overall health of the population
This is where the big incentive for preventive care comes in…with this plan, it is crucial to keep pts healthy
69
overall explaination of risk for FFS
FFS highest insurer risk, and high pt risk no provider risk
70
overall explanation of risk for DFFS
DFFS high insurer risk, some pt risk, no provider risk
71
Overall explanation of risk for perdiem
Perdiem some insurer risk, some provider risk no pt risk
72
overall explation of risk for case rates
Case rates low insurer risk high provider risk low pt risk
73
overall explantaion of risk for capitation
Capitation low insurer risk very high provider risk very low pt risk
74
Method of payment whereby a provider (usually a primary care physician) receives a fixed amount per member per month (PMPM) for a given covered population.
capitation
75
purpose of insurance
Mitigate (reduce) the financial risk of the insured (lost income)
76
in 3rd party payment sx, why is cost no longer a purchasing factor
customer (payor = insurer or employer) is no longer the consumer (user = patient)
Consumer is insulated from much of the cost, so cost is no longer a purchasing factor
77
where did the whole idea of employers paying for insurance stem from
In WW2 Wage freezes
Created incentive to increase fringe benefits in order to bargain with unions
Medical insurance quickly became a primary benefit that the employer paid for
78
what is community rating
This is when all covered companies were considered the same “risk” factors so they were all put in the same big pool
employer may pay more for community rating vs experience
79
what is experience rating
Insurance co’s began realizing that some co’s had younger healthier employees than others. number of employees per co was also taken into consideration (ex: Garmin is paying less than a local pizza place)
Larger co’s can spread their risk across a large number of employees. Smaller co’s are riskier and spread risk across small amt of pple so their rates are higher
80
indemnity plan (explain)
was old FFS
| insurance paid 100% and you could go anywhere
81
in old FFS, when did pt pay % of allowable
AFTER the service was performed
82
1st health care plan where pt choice was restricted
PPO
83
who had lower premiums, PPOs or FFSs
PPO had lower premium
84
other than less choice, what was bad about PPO
introduced utilization review
85
primary payment model for PPO
DFFS (discounted fee for service)
86
which plan type uses DFFS
PPO
87
the goal of a DFFS for PPO was to
decrease premiums for employers
88
why didn't DFFS for PPOs work
Providers increased their prices to compensate
Providers saw more patients (increased demand)
Providers did more procedures (increased volume
89
difference in PPOs then vs now
Old: pts used to just pay 10-20% of what the provider billed and the PPO paid the rest.
Now: pts pay copay, deductible, coinsurance and PPO pays what is left
90
co insurance % applies to the
allowable
| ex: if allowable is 1,000 and their co insurance is 20% it's 20% of 1000
91
how did insurance co's try to encourage pts to remain in network for PPOs
To encourage patients to remain in-network, PPOs charged different co-insurance rates
```
In-network = 10-20%
Out-of-network = 40-50%
```
92
when is co insurance paid
after the care
| if they are out of network they pay more
93
what is utilization review
```
done with PPOs
evaluating your decisions-
are they medically nessesary
Decisions made based on restrospective review of DOCUMENTATION
To pay or not to pay
```
94
who performs utillization reviews
Clerks
Nurses
Social workers
Not many PTs perform UR
95
who assumes risk with HMOs
PCP
96
6 main differences btwn HMO and PPO
HMOs have a more restricted provider network than PPOs
Gatekeeper role for primary care physicians = HMO
Capitation for primary care physicians HMO
No deductibles for HMO
Pre-authorization by insurer and/or PCP for non-PCP services for HMO
97
copays before services explains what plan
HMO
meant to be a Dis-incentive
now PPOs have copays too
98
in an HMO, the PCP is paid via what model
capitation
99
PCP is the gatekeeper is what plan
HMO
100
what are with-holds
used in HMOs
| the insurance co with-holds a certain % from the PMPM payments if goals are not met.
101
why might pts like HMOs
low premiums low OOP
102
why might pts hate HMOs
not very much choice
103
why might docs hate HMOs
they look like the bad guy
104
why do employers like HMOs
low premeiums
105
Insurance company owns all entities from the insurer to the providers
(what type of plan)
staff model HMO
| like Keiser Permentente
106
type of HMO with the lowest premiums
staff model HMO
107
Provides the most control over healthcare delivery
staff model HMO
| insurance has most control
108
what type of HMO is this
HMO contracts with one large multi-specialty physician group for all of their patients
Physicians do not work for the HMO
Can see patients from other insurers
group model
109
only model of HMO where docs are employed by the HMO
staff model
110
type of HMO model where the HMO contracts with numerous physician providers
network
111
what is an IPA HMO
independent practitioner association
| doc does contract with IPA that does a separate business contract with HMO.
112
what is POS HMO
point of service HMO
Point of Service (requires insurance to have an out of network option)
Allows patients to seek care outside of the HMO physician/hospital network
113
what is downfall of POS HMO
higher copays and co insurance for out of network
114
who assumes most risk in an HMO
provider
115
deductibles and co insurance are only used with what plans
FFS
| PPO
116
highest restricted provider networks is what group
HMO
117
what plan does utilization reviews
PPOs
118
what plan utilizes gate keepers and pre-authorization
HMO
119
what is HDHP
high deductible health plan (usually at least 5000)
120
goal of a HDHP
create financial incentive for patient to forego or put off purchasing healthcare
121
what is CDHP
Consumer Directed Health Plans
Combination of a Health Savings Account (HSA) or Medical Savings Account (MSA) and a high-deductible health plan
typically the employer starts the MSA
after you use your MSA or HSA pt pays deductible OOP
122
explain the correlation with taxes and a CDHP
MSA or HAS is a federally recognized healthcare savings account
Money left in the account is not taxed
123
who assumes risk with CDHP
pt *****
124
who assumes risk with HDHP
pt
125
theory behind CDHP and HDHP transferring risk to the pt
pt will be more sensitive and aware of pricing so decisions will be made on that concept
126
examples of for profit orgs
Examples:
Insurance companies (e.g., United Healthcare, Humana, Aetna, etc.)
HCA (own 220+ hospitals across USA)
Most physician offices, private practice PT clinics
127
examples of not for profit orgs
Examples:
Most hospitals
Some insurers (e.g., Blue Cross/Blue Shield)
Some nursing homes
128
FFS, who has the cost risk/responsibility
insurer
129
what type of plan uses DFFS & utilization review
PPO
130
HMO's cost responsibility borne by PCP’s through _____
capitation
131
if the allowable amt is 60$, but you bill 150$, how much are you actually paid by insurance
only the allowable (60)
132
medicare is for who
ALL elderly (65+ years old)
133
this is used by Medicare,
| Payment system whereby the payor knows what will be paid AHEAD OF TIME (prospectively) for diagnoses or procedures
PPS
134
another party assuming financial responsibility for the customer
Is meant to protect the customer from financial ruin in the case of expensive uncommon or unforeseen incidents
risk
135
in FFS, what payment is fixed and what varies
The Insurer is paid a fixed amount in the form of premiums from employers, but payments insurer makes to providers are variable based on demand and volume of health care services.
136
what is medical expense ratio
a term that applies to FFS
| the ratio btwn the premiums paid TO the insurance co and the payments paid to providers FROM the insurance co
137
the very first attempt by insurance cos to decrease costs for themselves (lowers the allowable)
Discounted Fee-For-Service (DFFS)
138
example of DFFS:
Total bill for PT = $1,000 and contract is for 40% DFFS =
(40% of 1000 = 400)
1000 - 400 = 600 (new allowable)
600
139
Fee schedule is a form of DFFS, but what is the main diff btwn the 2
Major difference is that if the provider raises prices then the provider will collect more with percent discount but will NOT collect more with a fee schedule
140
Paid per visit no matter what is performed or how long the visit lasts
Same payment for 10-minute visit versus a 90-minute visit
describes what type of plan
perdiem
141
example of case rate
OBGYN (baby delivery)
142
case rates are considered very___
efficient
143
in case rate, insurers hold 100% of the ___ risk while providers hold 100% of the ___ risk
insurers hold all demand risk
| providers hold all volume risk (providers can determine LOS)
144
primary objective of a DRG
to reduce LOS
| now hosp will get them out of the acute setting quicker bc of DRGs
145
example of a DRG
Example: DRG payment = $30,000 for five days.
Patient stays three days before being transferred to a SNF.
The per diem rate is $30,000 / 5 days = $6,000 per day. Therefore, the hospital is paid $6,000 X 3 days = $18,000 and not the full DRG amount of $30,000.
with a DRG, the hospital is only paid for the previously allotted days that the DRG accounts for based on their dx,
if they are transferred before the full DRG days, then the hospital is only paid perdiem for the days they were there
146
example of capitation
Physician signs up to cover 8,000 covered lives
Contract states physician receives $5 PMPM
8,000 X $5 = $40,000 per month to physician.
Physician receives $40,000 per month NO MATTER HOW MANY pts COME IN THAT MONTH OR HOW THEY ARE TREATED.
*
147
with capitation, provider may have free reign, but what is the downfall
if pt needs alot of care/tx and multiple visits, then the provider is loosing money
148
Is the only payment system that creates incentive for PREVENTION
Is the only payment system that creates provider incentive for patient not to use healthcare services
capitation/global capiation
149
order of progression of provider risk of all the plans
```
FFS plans
DFFS
Per Diem/Visit
Case Rate/DRG
then capitation
```
150
what % of pop was insured pre and post WW2
1. Before WW2 only 9% of the population had insurance
| 2. By 1952 over 50% of the population had insurance
151
true indemnity vs FFS
True indemnity plans differ from fee-for-service plans in that indemnity plans have the patient pay for health services FIRST. FFS is that the pt pays nothing up front and the provider sends claim to insurer.
152
BCBSMedicare of KC now requires (as of Jan 2016)
all pts to receive a PCP referral for all speciality services
153
medicare is a ____ org
FEDERAL
154
co insurance IN NETWORK fees are usually
10-20%
| out of network are more
155
what can be a downfall of fee schedule
insurer pays on a per CPT code basis, but the amount paid is a pre-negotiated amount that is NOT based on actual charges
No matter what you charge, you will only be paid what the prenegotiated amt is.
The dollar amount is the final result of your pre negotiations with the insurer
156
any profit made is put back into the business
not for profit
157
type of managed care where providers sign contracts with insurance co governing payment
PPO
158
Medicare is the same for all states T or F
T
| it's FEDERAL
159
in a CDHP, who takes up the cost responsibility
the pt
| consumer directed health plan
160
a CDHP is a combo of ___ and ___
medical savings
| high deductible
161
what plan used utilization review
PPO
162
fee schedule is related to
CPT codes
163
if deductible is met does pt still pay copay
yes
164
Keiser Permentente is an ex of what type of plan
staff HMO
| co owns ALL (providers to insurers)
165
in group model, do physicians work for the HMO
no
166
what does IPA stand for
independent practitioner associate
| these guys are contracted by docs to negotiate with HMOs
167
what does POS stand for
point of service
168
5 diff types of HMOs
```
staff
group
network
POS
IPA
```
169
with a fee schedule, does it make a difference if you charge more money for a tx
no, you only get the pre-negotiated amt that you and the insurance co decided for that cpt code
170
per diem, the longer the LOS the ____ $$ provider gets
more
171
with DFFS, providers would sometimes raise their individual tx prices in order to compensate for the overall cost of the visit...now, eventhough fee schedule is a form of DFFS, can fee schedule do this?
no, with fee schedule pricing is all based on the cpt codes
