Terminology Flashcards
What does PCP stand for?
primary care physician
What does GM stand for?
general practitioner
What does FM stand for?
family medicine
Who is considered a PCP?
1) Family Practice Physician
2) Internal Medicine Physician
3) Pediatrician
4) OB/GYN
Inpatient acute care is considered a Part _ Medicare service.
A
Outpatient care is considered a Part _ Medicare service.
B
What does IRF stand for?
Inpatient Rehab Facility
What type of patients are admitted into inpatient rehab facilities?
Post-acute patients in need of intensive rehab services
What does SNF stand for?
Skilled Nursing Facility
What is an important aspect of patients admitted into rehab facilities/SNF?
They have the potential to improve but are unsafe to return home
What does LTC stand for?
Long Term Care
What type of patient is admitted into a long term care facility?
people who can no longer care for themselves at home.
What does HHA stand for?
Home Health Agency
In what scenario do PT’s become similar to the patient’s PCP?
in home health situations in which they serve as the initial point of contact
What does AL/IL stand for?
Assisted living/Independent living
Describe assited living residents
People who are mostly independent but need some assistance in order to remain so
What is the difference between “For Profit” and “Not for Profit” health care systems?
In a for profit system all income (profit) generated from the enterprise can be paid to the shareholders (owners).
In a non for profit any income generated from the enterprise is put back into the business.
True or False
For profit organizations pay property and sales taxes
True
True or False
Non for profit organizations pay property and sales taxes
False
What is a deductible?
the annual amount the individual must pay before the health care plan begins to pay
Do Medicare patients have a deductible?
Yes – everyone has a deductible
What is a copayment?
the amount the individual must pay each time services or drugs or both are accessed
Do patients have to pay their copay even if they have met their deductible?
yes
Are copays always the same amount?
No, they vary according to the setting
What is coinsurance?
the percentage of the total cost that is paid by the individual while the remainder is paid by insurance AFTER the deductible is met
What is an allowable charge?
The maximum amount that an insurer will consider to pay for a service, including any amount that the patient will be responsible for paying.
This means that although you may charge a patient for $115 worth of charges, you will only get paid the insurances allowed amount which can be less than the services provided.
What does EOB stand for?
Explanation of Benefits
What does the explanation of benefits describe?
what a patient’s insurance will pay for and what it will not.
What does CDHP stand for?
Consumer Directed Health Plan
Describe the basics of a consumer directed health plan
It is a health plan that includes the ability to use a medical savings account and also have a high deductible
What is a FSA (flex spending amount)?
a special account you put money into that you use to pay for certain out-of-pocket health care costs.
This money is non-taxable
What is a downfall to using a flex spending account over a health savings account?
Funds in a FSA are lost when the plan year is over, whereas they are not in a HSA
What is a utilization review?
a process through which an outside reviewer (usually a nurse) reviews a process (in our case a course of Physical Therapy with a patient) to see if it meets the standards of care
What does a CPT code stand for?
Current Procedural Terminology
What does ICD stand for?
International Classification of Diagnoses
What country was the last to begin using ICD-10?
The US
What is the process that new providers have to go through to become in network providers for insurance carriers called?
Credentialing
What is a managed care plan?
a system of health care in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company
What are the 3 types of managed care plans?
- Preferred Provider Organization (PPO)
- Health Maintenance Organization (HMO)
- Point-of-Service Plans (POS)
Describe how a PPO works
It is a health plan that has contracts with a network of “preferred” providers from which patients can choose from and if they see one of these doctors they only be responsible for their annual deductible and a copayment for the visit
Describe how a HMO works
Patients must choose a PCP who is responsible for managing and coordinating all of their health care. If they need care from a physician specialist their PCP will have to provide them with a referral.
Describe how a POS works
The patient can decide to stay in network and allow their PCP to manage their care or go outside the network on their own without a referral from their PCP
Describe how a fee for service (FFS) plan works
Doctors charge a fee for their services. They then bill the insurer and the insurer pays the claim. The patient is then billed retrospectively after the fact
What is the problem with FFS?
it is causing inflation in the health care field
Describe how a prospective payment system (PPS) works
It is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount dependent upon diagnosis or procedure
What is a Diagnosis-Related Group (DRG)?
a statistical system of classifying any inpatient stay into groups for the purposes of payment
What are Resource Utilization Groups (RUGs)?
It is a categorization program used by Medicare based on functional status and anticipated use of services and resources for patients typically in nursing homes
Describe the pay for performance model
It is a new model of reimbursement that has gained momentum over the last several years to reward outcomes rather than the number of services performed
The “paid by the head” phrase can be used to describe what payment method?
capitation
Describe capitation payment services
It pays a physician a set amount for each enrolled person assigned to them, per period of time, regardless of the number or severity of their conditions
Who typically is the third part payor in the US?
the insurance company
The patient is the 1st party, the healthcare provider is the 2nd party, and the insurance company is the 3rd party who pays the provider instead of the patient directly paying the providers
What is the difference between private and public insurance?
Private: a health care plan offered by a nongovernment insurance
Public: a health care plan offered by a government insurance
Give a few examples of private insurances
- Humana
- Aetna
- BCBS
- United Healthcare
Give a few examples of public insurances
- Medicare
- Medicaid
- Veterans Administration
- Tri-Care (military)
The Center for Medicare Services provides a federally insured benefit plan to all elderly over the age of __ years
65
If a patient over the age of 65 choses to opt out of traditional Medicare and be covered by a private insurer what is the result?
Medicare pays the patient’s premium and the patient picks up part of the cost
What is the name of the insurance benefit plan for the poor?
Medicaid
