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)
2
Q
Not for profit
A
- Any profit generated from the enterprise is put back into the business; NO shareholders/owners
3
Q
Deductible
A
the amount the patient must pay annually before the insurer will pay anything
4
Q
Copay
A
- the amount patient pays at time of service ALL YEAR (even after deductible is met)
5
Q
Coinsurance
A
- percentage of the total cost that the patient must pay
6
Q
Private insurance
A
- non-government
Example: BCBS, United
7
Q
Public insurance
A
- government insurance
Example: Medicare, Medicaid, tri-care
8
Q
Fee for service (FFS)
A
AKA “indemnity” provider bills the insurer, so cost responsibility is that of the insurers
9
Q
Preferred provider organization (PPO)
A
providers sign contracts governing payment and the number of physicians in the network is restricted
10
Q
Health Maintenance Organization (HMO)
A
- cost responsibility lies with PCP’s through capitation = so this reduced health care costs
11
Q
Consumer Directed Health Plan (CDHP)
A
cost responsibility of the patient
12
Q
Claim
A
what the provider submits to insurance
13
Q
Explanation of benefits
A
defines the allowable
14
Q
Allowable
A
total amount the provider is paid per the contract with the insurer
15
Q
Medicare
A
federal insurance for all elderly ages 65+
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
17
Q
Medicaid
A
insurance plan for the poor
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
19
Q
Demand risk
A
- how many people seek out the service
20
Q
Volume (utilization) risk
A
types of services performed, quantity of services, and length of time of service
21
Q
FFS incentives
A
no incentives for quality or cost containment
22
Q
FFS risk
A
insurer at financial risk
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
24
Q
DFFS incentives
A
no incentive for quality or cost containment
25
DFFS risk
insurer at risk
26
What is fee schedule?
each billing code has a fixed payment tied to it
27
Fee schedule incentives
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
Fee scheduling risk
insurer bears all demand and risk volume; provider bears some volume
29
Per Diem payment methods (outpatient)
pay per visit
30
Per Diem outpatient incentives
decrease overall clinic costs, decrease time span of visits, no incentive for quality
31
Per Diem outpatient risk
provider and insurer are both at risk
32
Per Diem payment methods (inpatient)
facility is paid all inclusive daily rate
33
Per Diem inpatient incentives
- efficient care, team-focused, no incentive for controlling length of stay
34
Per Diem inpatient risk
provider and insurer at risk
35
Case Rates (“Per case”)
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
Case Rates Incentives
leads to VERY efficient care, want quick discharge, early discharge, want to see more patients in a day
37
DRG (Diagnosis Related Group)
Medicare related; case rates for acute hospital inpatient units, where facility is paid one lump sum for ALL services for entire LOS
38
DRG Incentives
want to reduce LOS, want quick discharge, want high volume of patients
39
DRG Risk
provider mainly at risk during acute stay, Medicare at risk in post-acute transfers
40
Capitation
- 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
Capitation incentives
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
Global Capitation
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
Global Capitation Incentives
provider held accountable for all services and costs, decrease LOS, want to focus on prevention
44
Global Capitation Risk
full risk of provider
45
Bundled Payment
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
Bundle Payment Incentives
incentive to discharge patients to home, or low-cost post-op care
47
What is the purpose of insurance?
Insurance is intended to mitigate (reduce) the financial risk of the insured (e.g., lost income)
48
What is community rating?
everyone in that insurance plan pays the same premium
49
What is experience rating?
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
Who is discriminated against with higher experience ratings?
people with pre-existing conditions
51
What is indemnity?
patient pays for the health service first, then submists receipts to insurance for reimbursement
52
Utilization review/utilization management
retrospective auditing of medical records to judge validity of bill
53
With HMO’s PCP’s are considered
gatekeepers (so PCP must refer patients for other services)
54
HMO Type: Staff Model
providers are employees of the insurance company (encourages prevention since physicians are paid a salary)
55
HMO Type: Group Model
a large multi-specialty group serves as caregivers for large group of enrollees (group is paid by capitation )
56
HMO Type: Network HMO
HMO contracts with providers already in existence, so physicians do not work for HMO but still receive reimbursement from it
57
HMO Type: Independent Practitioner Association (IPA) Model
- 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
HMO Type: Point of Service (POS)
encourages patients to seek out of HMO network. Pros: enrollees have more choice. Cons: more expensive, loss of gatekeeper function
59
Goal of High Deductible Health Plan
create financial incentive for patient to forego or put off purchasing healthcare (more finiancial risk on patient)
60
Consumer Directed Health Plan (CDHP)
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
Prescription Drug Act of 2003
authorized tax-exempt, employer sponsored MSAs, which increased the popularity of MSA’s.
62
Very High Premiums
indemnity plans using FFS payment methods
63
High Premiums
PPOs and DFFS payment methods
64
Medium Premiums
HMOs using per diem/visit, case rates, or capitation
65
Low Premiums
HDHP, CDHP
