Reimbursement and Research

Question 1

First Party

Answer 1

Patient

Question 2

Second Party

Answer 2

Health Care Professional delivering services

Question 3

Third Party

Answer 3

Insurer

Question 4

Payer

Answer 4

the insurer who makes the payment for services under the insurance coverage policy

Question 5

Capitation

Answer 5

a reimbursement method that pays the provider a set fee each month, based on the number of patients enrolled in the insurance plan.

Question 6

Capitated payment

Answer 6

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.

Question 7

Fee-for-service

Answer 7

a payment for specific health care services that were provided to a patient

Question 8

Medicare is a health insurance provider for…

Answer 8

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)

Question 9

People age 65 or older can apply for?

Answer 9

medicare

Question 10

any age with end stage renal disease (perm. Kidney failure needing dialysis or kidney transplant) can apply for?

Answer 10

medicare

Question 11

under age 65 with certain disabilities can apply for?

Answer 11

medicare

Question 12

Largest provider of health care services in the US?

Answer 12

medicare

Question 13

established in 1965 as part of the social security act

Answer 13

medicare

Question 14

Medicare Part A

Answer 14

covers inpatient care (but not long term care), hospice and some home health care

Question 15

Medicare Part B

Answer 15

covers doctors services and outpatient care, some home health care, DME (durable medical equipment)

Question 16

Medicare Part C (medicare Advantage)

Answer 16

Monthly premiums
provided by private companties approved by medicare
covers same as parts A and B plus additional services amd Rx

Question 17

Medicare D

Answer 17

Monthly premiums
prescription drugs
available to those with parts A and B

Question 18

Current cap for Medicare?

Answer 18

$1900

patient can receive 1900 in PT and SLP services in a calendar year (jan1-dec31)

Question 19

KX modifier?

Answer 19

the requirement to billing indicating services are reasonable and necessary to extent the cap for medicare.
extended to 3700

Question 20

When do exceptions to KX modifier expire?

Answer 20

Dec31

Question 21

G-codes

Answer 21

Functional limitations reporting at eval, and no more than every 10th visit, and at discarge (PT resposibility)

Question 22

Medicaid

Answer 22

state and federally funded
state run 
provides medical and health-related services
enacted in 1965 part of social security
small copay usually required

Question 23

What people are covered under medicaid?

Answer 23

kids
disables, blind or pregnant
financial resources
US citizen or lawfully admitted immigrant

Question 24

HMO

Answer 24

health maintenance organizations

Question 25

HMO function

Answer 25

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

Question 26

PPO

Answer 26

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

Question 27

Managed care

Answer 27

a system in which the provision of benefits and services are controlled;administrative incentives and constraints

Question 28

Current procedural terminology (CPT)

Answer 28

condes assigned to health care service and billing and reimbursement