Terminology Flashcards
For Profit
Any profit generated from the enterprise can be paid to shareholders (owners)
Who uses a For Profit model
Most physician offices, private practice PT clinics
Not for Profit
Any profit generated from the enterprise is put back into the business NO shareholders (owners)
who uses Not for Profit model
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
Copay
Amount patient pays at time of service ALL YEAR (even after deductible is met)
Co-Insurance
A percentage of the total cost that the patient must pay
what is the range for Co-insurance?
10%-20%
Private Insurance
non-government insurance
examples of private insurance
Humana, Aetna, Blue Cross Blue Shield, United Healthcare
Public Insurance
government insurance
examples of gov’t insurance
Medicare
Medicaid
Veterans Administration
Tri-Care (military)
Fee For Service (FFS)
Provider billed insurer and insurer paid the claim
Fee for service can also be called
indemnity
The dominant pay system until 1990 was
FFS
Managed Care
PPO’s and HMO’s
Preferred Provider Organization (PPO)
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.
Health Maintenance Organization ( HMO)
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
Why did HMO’s gain popularity in the 1990’s
Reduced premium costs
Reduced health care cost
PCP
Primary Care Provider
Example of PCP
Family Practice Physician
Internal Medicine Physician
Pediatrician
OB/GYN
CDHP
Consumer Directed Health Plan
What is CDHP a combination of
Medical Savings Account (MSA) and a high deductible health plan
Claim
What the provider submits to the insurer
