Reimbursement/Third-Party Payers for Health Care Services Flashcards
Provides medical coverage and health care services to individual ≥65 years , with permanent kidney failure or other long. term disabilities at <65 years.
Medicare
Established Medicare’s prospective payment system.
Social Security Amendment of 1983
ii. Classification system that places patients into disease categories or groups.
ii. Basis for Medicare’s prospective payment system
Based on diagnostic-related groups (DRGs)
a. Hospital insurance that covers:
i. Inpatient hospital care
ii. Provides basic protection against the cost of health care
iii. Does not cover all medical expenses or that cost long-term care
Medicare Part A
Medicare Part A: Hospital Insurance that covers:
- Inpatient hospital care
- Provides basic protection against the cost of healthcare
- does not cover all medical expenses or that cost long-term care
a. medical insurance that covers
b. PT treatment does not need to be given on a daily basis.
Medicare Part B
Medical insurance that covers in Medicare Part B
i. physician visit
ii. outpatient lab test and xray
iii. ambulance transport
iv. outpatient PT and OT services
v. homehealth care provided by a PT in a independent practice
vi. durable medical equipment
vii. medical supplies not covered by hospital insurance
viii. residents of long term care facilities
c. joint state and federal program mandated
d. Provides health care services to the poor, elderly. and disabled who do not receive Medicare, regardless of age.
e. Benefits vary from state to state.
f. Preauthorization is needed by a physician before treatment can begin.
Medicaid
Includes commercial insurance, fee-for-service or traditional indemnity plans, or employers who are self-insured.
Private Health Insurance
Patient has freedom to choose his/her providers.
Private Health Insurance
The number of PT visits should be usual, customary, and reasonable, which are often defined contractually in the insurance policy
Private Health Insurance
direct patients to certain providers and monitor services n order to avoid excessive ad inappropriate treatment and limit access
third party
A form of managed care that provides a broad spectrum of health-services to individuals and families for a preset amount of money.
health maintenance organization
Individuals without health insurance must personally pay for all medical care.
Personal payment and free care
Individuals who cannot pay for health care can receive pro bono, or free, care through philanthropic donations and services.
personal payment and free care
