Terminology Flashcards
For Profit
-any profit generated from the enterprise can be paid to shareholders (owners)
-pay property & sales taxes
Ex: insurance companies, HCA, most physician offices or private practice PT clinics
Not For Profit
-any profit generated from the enterprise is put back into the business
-NO shareholders (owners)
-do NOT pay property & sales taxes
Ex: most hospitals, some insurers (e.g., Blue Cross/Blue Shield), some nursing homes
Deductible
-the amount the patient must pay before the insurer will pay anything
Co-Pay
-amount patient pays at time of service ALL YEAR (even after deductible is met)
Ex: $40 per visit co-pay for outpatient & $150 co-pay for hospital
Co-Insurance
-a percentage of the total cost that the patient must pay
-usually ranges from 10-20% for in-network services
Ex: 20% co-insurance. Patient may pay 20% of what provider bills, patient may pay 20% of what insurer pays, depends on patient’s coverage
Private Insurance vs. Public Insurance
-private insurance = non-government insurance
Ex: Humana, Aetna, BCBS, United Healthcare, etc.
-public insurance = government insurance
Ex: Medicare, Medicaid, Veterans Administration, Tri-Care (military)
FFS
- fee for service (sometimes still called “indemnity”
- provider billed insurer & insurer paid the claim
- patient usually paid 20% after the fact
- new idea = cost responsibility borne by the insurers
- dominant payment system until 1990’s
Managed Care
- largely an irrelevant term now, “managed care” dominated the 1990’s first with PPO’s (not very successful), then with HMO’s
- HMO’s were successful in reducing healthcare inflation for the first time in American history
PPO
- preferred provider organization
- a form of “managed care” begun in the 1980’s whereby providers sign contracts governing payment
- insurers offer lower premiums by restricting the provider panel (number of physicians in the network)
- new ideas: DFFS & utilization review
HMO
- health maintenance organization
- new idea = cost responsibility borne by PCP’s through capitation
- gained popularity in 1990’s for: reduced premium costs, reduced health care costs
- unpopular due to methods used to gain those results and patient loses choice
PCP
-primary care practitioner/provider
Ex: family practice physician, internal medicine physician, pediatrician, OB/GYN
CDHP
- consumer directed health plan
- usually combination of medical savings account (MSA) & a high deductible health plan
- new idea = cost responsibility borne by the patient
Claim
- what the provider submits to the insurer
- is a “claim” for payment
- mainly electronic now
- used to be paper based & some still are
- each private insurer can (and does) have different claim submission & adjudication systems
EOB
- explanation of benefits
- will define the allowable = what the insurer will pay
- is the definitive document of what the provider will be paid by insurer & patient
- example for an EOB for a $49,000 outpatient procedure
Allowable
-the amount the insurer will pay
-will be defined on the EOB
Ex: per visit rate; Your contract calls for you to be paid $60 per outpatient visit, the $60 is the allowable, even if the visit lasts one hour & you will $450 then you will be paid $60.
Medicare
- FEDERAL insurance benefit plan for ALL elderly (65+ years old)
- uniform benefits across all states
- administered under the health & human services (HHS) department by the center for medicare & medicaid services (CMS)
- passed in 1965 & began in 1966
MRP
- medicare replacement plans
- “medicare managed care”
- patients can opt out of traditional medicare & be covered by a private insurer (e.g., Humana, United Healthcare, etc.)
- Medicare pays the patient’s premium
Medicaid
- insurance benefit plan for the poor
- funded by federal & state
- administered by the state
- core benefits guaranteed by federal law
- other benefits (including PT, OT, SLP) decided upon by each state
- eligibility varies state by state
CPT-4
- current procedural terminology - version 4
- billing system using procedure codes
- developed & owned by the American Medical Association (AMA)
- is the de facto procedure billing standard in the USA
ICD-9
- international classification of diagnoses - version 9
- diagnostic coding system used by most countries to classify patient diagnoses
PPS
- prospective payment system
- adopted by medicare with TEFRA in 1983 with DRG’s then with BBA 1997
- payment system whereby the payor knows what will be paid AHEAD OF TIME (prospectively) for diagnoses or procedures
- provider charges are largely irrelevant
DRG
- diagnosis related group
- first medicare PPS
- fully in effect in 1987 for acute hospitals
- hospital is paid in one lump sum for the entire length of stay = CASE RATE
- gone were the days of charging for every procedure, service (PT), etc.
Acute (Hospital)
-“regular” hospital bed, includes intensive care units
IRF
- inpatient rehabilitation facility
- post-acute facility for patients in need of intensive rehabilitation (PT, OT, SLP)
- 3+ hours of PT, OT, SLP per day
- minimum of 5 days of therapy per week
- patients should have the potential to return home
SNF
- skilled nursing facility
- post-acute facility for patients in need of continued nursing &/or rehab care
- patients not yet ready or safe to return home
- need less than 3 hours per day of rehab
- patients with potential to improve but may not return home
LTC
- long term care facility
- “nursing home”
- residential facility for people who can no longer care for themselves at home
AL / IL
- assisted living (AL) = residential apartment-like facility for those who are mostly independent but need some assistance in order to remain so
- independent living (IL) = residential apartment-like facility for those who are independent; meal, laundry, & activity services provided
HHA
- home health agency
- post-acute service for homebound patients to receive nursing &/or rehabilitation (PT, OT, SLP) care in their home
OP
- outpatient services
- wide range of pre or post-acute services provided by a wide range of providers [physicians, hospitals, PT’s, free standing radiology & lab facilities]
