Reimbursement and Research Flashcards
First Party
Patient
Second Party
Health Care Professional delivering services
Third Party
Insurer
Payer
the insurer who makes the payment for services under the insurance coverage policy
Capitation
a reimbursement method that pays the provider a set fee each month, based on the number of patients enrolled in the insurance plan.
Capitated payment
a form of reimbursement for health care services in which a health provider is paid a predetermined (fixed) amount for each patient enrolled in his or her care.
Fee-for-service
a payment for specific health care services that were provided to a patient
Medicare is a health insurance provider for…
People age 65 or older,
under age 65 with certain disabilities,
any age with end stage renal disease (perm. Kidney failure needing dialysis or kidney transplant)
People age 65 or older can apply for?
medicare
any age with end stage renal disease (perm. Kidney failure needing dialysis or kidney transplant) can apply for?
medicare
under age 65 with certain disabilities can apply for?
medicare
Largest provider of health care services in the US?
medicare
established in 1965 as part of the social security act
medicare
Medicare Part A
covers inpatient care (but not long term care), hospice and some home health care
Medicare Part B
covers doctors services and outpatient care, some home health care, DME (durable medical equipment)
Medicare Part C (medicare Advantage)
Monthly premiums
provided by private companties approved by medicare
covers same as parts A and B plus additional services amd Rx
Medicare D
Monthly premiums
prescription drugs
available to those with parts A and B
Current cap for Medicare?
$1900
patient can receive 1900 in PT and SLP services in a calendar year (jan1-dec31)
KX modifier?
the requirement to billing indicating services are reasonable and necessary to extent the cap for medicare.
extended to 3700
When do exceptions to KX modifier expire?
Dec31
G-codes
Functional limitations reporting at eval, and no more than every 10th visit, and at discarge (PT resposibility)
Medicaid
state and federally funded state run provides medical and health-related services enacted in 1965 part of social security small copay usually required
What people are covered under medicaid?
kids
disables, blind or pregnant
financial resources
US citizen or lawfully admitted immigrant
HMO
health maintenance organizations
HMO function
a type of managed care organization (MCO) that is provided by a limited number of professionals for a fixed fee
monitors and limits excessive expeditures
Must see PCP before specialists, only see providers within the network
initially created to decrease cost by providing preventative services
PPO
a variation (in regards to HMO) in which patients can visit physicians outside of the network for increased costs and can visit specialists without referral
Managed care
a system in which the provision of benefits and services are controlled;administrative incentives and constraints
Current procedural terminology (CPT)
condes assigned to health care service and billing and reimbursement
