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Healthcare Management Quiz 1 > Quiz 1 > Flashcards

Quiz 1 Flashcards

1
Q

For profit

A
  • Any profit generated from the enterprise can be paid to shareholders (owners)
    Example: insurance companies (united, humana, etc)
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2
Q

Not for profit

A
  • Any profit generated from the enterprise is put back into the business; NO shareholders/owners
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3
Q

Deductible

A

the amount the patient must pay annually before the insurer will pay anything

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4
Q

Copay

A
  • the amount patient pays at time of service ALL YEAR (even after deductible is met)
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5
Q

Coinsurance

A
  • percentage of the total cost that the patient must pay
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6
Q

Private insurance

A
  • non-government

Example: BCBS, United

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7
Q

Public insurance

A
  • government insurance

Example: Medicare, Medicaid, tri-care

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8
Q

Fee for service (FFS)

A

AKA “indemnity” provider bills the insurer, so cost responsibility is that of the insurers

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9
Q

Preferred provider organization (PPO)

A

providers sign contracts governing payment and the number of physicians in the network is restricted

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10
Q

Health Maintenance Organization (HMO)

A
  • cost responsibility lies with PCP’s through capitation = so this reduced health care costs
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11
Q

Consumer Directed Health Plan (CDHP)

A

cost responsibility of the patient

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12
Q

Claim

A

what the provider submits to insurance

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13
Q

Explanation of benefits

A

defines the allowable

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14
Q

Allowable

A

total amount the provider is paid per the contract with the insurer

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15
Q

Medicare

A

federal insurance for all elderly ages 65+

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16
Q

Medicare Advantage Plan

A

elderly patients can opt out of Medicare’s plan for another commercial insurer, but Medicare pays the patient’s premium to the commercial insurer

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17
Q

Medicaid

A

insurance plan for the poor

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18
Q

What is “risk”?

A
  • Another party assuming financial risk for the customer; protects customer from financial ruin in case of expensive unforeseen incidents
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19
Q

Demand risk

A
  • how many people seek out the service
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20
Q

Volume (utilization) risk

A

types of services performed, quantity of services, and length of time of service

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21
Q

FFS incentives

A

no incentives for quality or cost containment

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22
Q

FFS risk

A

insurer at financial risk

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23
Q

What is discounted fee for service (DFFS)?

A

attempt by insurers to decrease cost by establishing that a certain % of the charge is subtracted off the top

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24
Q

DFFS incentives

A

no incentive for quality or cost containment

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25
Q

DFFS risk

A

insurer at risk

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26
Q

What is fee schedule?

A

each billing code has a fixed payment tied to it

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27
Q

Fee schedule incentives

A

incentive to do more of the codes that pay well, less of the low-paying codes; no incentive for quality, some incentive for cost containment

28
Q

Fee scheduling risk

A

insurer bears all demand and risk volume; provider bears some volume

29
Q

Per Diem payment methods (outpatient)

A

pay per visit

30
Q

Per Diem outpatient incentives

A

decrease overall clinic costs, decrease time span of visits, no incentive for quality

31
Q

Per Diem outpatient risk

A

provider and insurer are both at risk

32
Q

Per Diem payment methods (inpatient)

A

facility is paid all inclusive daily rate

33
Q

Per Diem inpatient incentives

A
  • efficient care, team-focused, no incentive for controlling length of stay
34
Q

Per Diem inpatient risk

A

provider and insurer at risk

35
Q

Case Rates (“Per case”)

A

Provider is paid for the whole case, no matter what was provided and no matter the LOS. Provider gets a “lump sum” for all appointments (example: OB/GYN gets paid lump sum for visits, delivery, etc.)

36
Q

Case Rates Incentives

A

leads to VERY efficient care, want quick discharge, early discharge, want to see more patients in a day

37
Q

DRG (Diagnosis Related Group)

A

Medicare related; case rates for acute hospital inpatient units, where facility is paid one lump sum for ALL services for entire LOS

38
Q

DRG Incentives

A

want to reduce LOS, want quick discharge, want high volume of patients

39
Q

DRG Risk

A

provider mainly at risk during acute stay, Medicare at risk in post-acute transfers

40
Q

Capitation

A
  • insurer pays a flat rate per member per month to the provider; no matter how many patients or services provided, it is still the same payment
  • Capitation risk = provider assumes risk
41
Q

Capitation incentives

A

provider held accountable for costs and care, decreased utilization/number of office visits, decrease LOS, want to focus on preventative care and keep patients out of the office

42
Q

Global Capitation

A

one provider receives one lump sum per beneficiary per year for a given group of insured beneficiaries (that one lump sum covers ALL healthcare for patients for entire year)

43
Q

Global Capitation Incentives

A

provider held accountable for all services and costs, decrease LOS, want to focus on prevention

44
Q

Global Capitation Risk

A

full risk of provider

45
Q

Bundled Payment

A

one provider is paid for the care provided by multiple providers OR one provider is put at financial risk for the care provided by multiple providers

46
Q

Bundle Payment Incentives

A

incentive to discharge patients to home, or low-cost post-op care

47
Q

What is the purpose of insurance?

A

Insurance is intended to mitigate (reduce) the financial risk of the insured (e.g., lost income)

48
Q

What is community rating?

A

everyone in that insurance plan pays the same premium

49
Q

What is experience rating?

A

businesses pay different premium amounts based on the health (or healthcare utilization) of their employees even if they are all covered by the same insurance company (so if an employer has healthy people, they pay less in premiums)

50
Q

Who is discriminated against with higher experience ratings?

A

people with pre-existing conditions

51
Q

What is indemnity?

A

patient pays for the health service first, then submists receipts to insurance for reimbursement

52
Q

Utilization review/utilization management

A

retrospective auditing of medical records to judge validity of bill

53
Q

With HMO’s PCP’s are considered

A

gatekeepers (so PCP must refer patients for other services)

54
Q

HMO Type: Staff Model

A

providers are employees of the insurance company (encourages prevention since physicians are paid a salary)

55
Q

HMO Type: Group Model

A

a large multi-specialty group serves as caregivers for large group of enrollees (group is paid by capitation )

56
Q

HMO Type: Network HMO

A

HMO contracts with providers already in existence, so physicians do not work for HMO but still receive reimbursement from it

57
Q

HMO Type: Independent Practitioner Association (IPA) Model

A
  • providers contracted with HMO through a physician agency (IPA). Pros: can see patients of all insurers. Cons: middle man (IPA) takes some revenue, and some physicians in IPA may be higher utilizers than others in same group
58
Q

HMO Type: Point of Service (POS)

A

encourages patients to seek out of HMO network. Pros: enrollees have more choice. Cons: more expensive, loss of gatekeeper function

59
Q

Goal of High Deductible Health Plan

A

create financial incentive for patient to forego or put off purchasing healthcare (more finiancial risk on patient)

60
Q

Consumer Directed Health Plan (CDHP)

A

medical savings account (MSA) + high deductible plan (basically, enrollees end up paying for their own services using their medical savings account, so patients become PRICE SENSITIVE)

61
Q

Prescription Drug Act of 2003

A

authorized tax-exempt, employer sponsored MSAs, which increased the popularity of MSA’s.

62
Q

Very High Premiums

A

indemnity plans using FFS payment methods

63
Q

High Premiums

A

PPOs and DFFS payment methods

64
Q

Medium Premiums

A

HMOs using per diem/visit, case rates, or capitation

65
Q

Low Premiums

A

HDHP, CDHP

Healthcare Management Quiz 1 (1 decks)

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