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Healthcare Management > Terminology > Flashcards

Terminology Flashcards

1
Q

For Profit

A

Any profit generated from the enterprise can be paid to shareholders (owners)

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2
Q

Who uses a For Profit model

A

Most physician offices, private practice PT clinics

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3
Q

Not for Profit

A 
Any profit generated from the enterprise is put back into the business
NO shareholders (owners)
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4
Q

who uses Not for Profit model

A

Most hospitals
Some insurers (e.g., Blue Cross/Blue Shield)
Some nursing homes

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5
Q

Deductible

A

The amount the patient must pay before the insurer will pay anything

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6
Q

Copay

A

Amount patient pays at time of service ALL YEAR (even after deductible is met)

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7
Q

Co-Insurance

A

A percentage of the total cost that the patient must pay

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8
Q

what is the range for Co-insurance?

A

10%-20%

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9
Q

Private Insurance

A

non-government insurance

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10
Q

examples of private insurance

A

Humana, Aetna, Blue Cross Blue Shield, United Healthcare

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11
Q

Public Insurance

A

government insurance

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12
Q

examples of gov’t insurance

A

Medicare
Medicaid
Veterans Administration
Tri-Care (military)

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13
Q

Fee For Service (FFS)

A

Provider billed insurer and insurer paid the claim

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14
Q

Fee for service can also be called

A

indemnity

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15
Q

The dominant pay system until 1990 was

A

FFS

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16
Q

Managed Care

A

PPO’s and HMO’s

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17
Q

Preferred Provider Organization (PPO)

A

PPO plans allow you to visit whatever in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician.

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18
Q

Health Maintenance Organization ( HMO)

A

an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities in the United States and acts as a liaison with health care providers

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19
Q

Why did HMO’s gain popularity in the 1990’s

A

Reduced premium costs

Reduced health care cost

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20
Q

PCP

A

Primary Care Provider

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21
Q

Example of PCP

A

Family Practice Physician
Internal Medicine Physician
Pediatrician
OB/GYN

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22
Q

CDHP

A

Consumer Directed Health Plan

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23
Q

What is CDHP a combination of

A

Medical Savings Account (MSA) and a high deductible health plan

24
Q

Claim

A

What the provider submits to the insurer

25
Q

Explanation Of Benefits (EOB)

A

Will define the allowable = what the insurer will pay to the PROVIDER (you) and the patient

26
Q

What is the definitive document of what the provider will be paid by insurer & patient

A

Explanation of Benefits

27
Q

Allowable

A

The amount the insurer will pay

28
Q

Where is the allowable defined?

A

Defined in the EOB

29
Q

What is the amount the PT will be paid by the insurer?

A

Allowable

30
Q

Medicare

A

FEDERAL insurance benefit plan for ALL elderly (65+ years old)

31
Q

What two organizations administer Medicare

A

Dept of Health and Human Services (HHS)

Center of medicare and medicaid services (CMS)

32
Q

When did medicare begin

A

1966

33
Q

Medicare Replacement Plans (MRP)

A

Patients can opt out of traditional Medicare and be covered by a private insurer (e.g., Humana, United Healthcare, etc.)
Medicare pays the patient’s premium

34
Q

an MRP is also called

A

Medicare Managed Care

35
Q

Medicaid

A

Insurance benefit plan for the poor

36
Q

who pays for medicare

A

Federal and State

37
Q

Does eligibility for medicaid vary

A

Yes, state by state basis

38
Q

Is PT covered by Medicaid

A

Yes, but it varies state by state

39
Q

What is CPT-4

A

Current Procedural Terminology – Version 4

40
Q

Who developed and owns CPT-4 codes

A

American Medical Association

41
Q

What is the de facto billing standard in the USA

A

CPT codes

42
Q

What is ICD-9

A

International Classification of Diagnoses – Version 9

43
Q

What is the difference between ICD-9 and ICD-10

A

ICD-10 is more sensitive and there are more codes

44
Q

Prospective Payment System (PPS)

A

Payment system whereby the payor knows what will be paid AHEAD OF TIME (prospectively) for diagnoses or procedures

45
Q

Diagnosis Related Group

DRG

A

Hospital is paid one lump sum for the entire length of stay = CASE RATE

46
Q

What was the first Medicare PPS

A

DRG

47
Q

Acute Hospital

A

Regular” hospital bed

Includes intensive care units

48
Q

Inpatient Rehabilitation Facility

IRF

A

Post-acute facility for patients in need of intensive rehabilitation (PT, OT, SLP)

49
Q

What requirements does the patient need to meet to attend an IRF

A

3+ hours of PT, OT, SLP per day
Minimum of 5 days of therapy per week
Patients should have the potential to return home

50
Q

Skilled Nursing Facility (SNF)

A

Post-acute facility for patients in need of continued nursing and/or rehab care

51
Q

What requirements does the patient need to meet to attend an SNF

A

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

52
Q

Long Term Care facility (LTC)

A

Residential facility for people who can no longer care for themselves at home

53
Q

Assisted Living (AL)

A

Residential apartment-like facility for those who are mostly independent but need some assistance in order to remain so

54
Q

Independent Living (IL)

A

Residential apartment-like facility for those who are independent
Meal, laundry, and activity services provided

55
Q

Home Health Agency (HHA)

A

Post-acute service for homebound patients to receive nursing and/or rehabilitation (PT, OT, SLP) care in their home

56
Q

Outpatient services (OP)

A

Wide range of pre or post-acute services provided by a wide range of providers

57
Q

Examples of OP

A

Physicians
Hospitals (radiology, lab, PT/OT/SLP, etc.)
PT’s (private practices)
Free standing radiology and lab facilities

Healthcare Management (5 decks)

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