Terminology Flashcards

1
Q

For Profit

A

-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

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2
Q

Not For Profit

A

-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

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3
Q

Deductible

A

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

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4
Q

Co-Pay

A

-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

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5
Q

Co-Insurance

A

-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

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6
Q

Private Insurance vs. Public Insurance

A

-private insurance = non-government insurance
Ex: Humana, Aetna, BCBS, United Healthcare, etc.
-public insurance = government insurance
Ex: Medicare, Medicaid, Veterans Administration, Tri-Care (military)

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7
Q

FFS

A
  • 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
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8
Q

Managed Care

A
  • 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
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9
Q

PPO

A
  • 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
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10
Q

HMO

A
  • 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
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11
Q

PCP

A

-primary care practitioner/provider

Ex: family practice physician, internal medicine physician, pediatrician, OB/GYN

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12
Q

CDHP

A
  • consumer directed health plan
  • usually combination of medical savings account (MSA) & a high deductible health plan
  • new idea = cost responsibility borne by the patient
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13
Q

Claim

A
  • 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
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14
Q

EOB

A
  • 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
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15
Q

Allowable

A

-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.

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16
Q

Medicare

A
  • 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
17
Q

MRP

A
  • 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
18
Q

Medicaid

A
  • 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
19
Q

CPT-4

A
  • 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
20
Q

ICD-9

A
  • international classification of diagnoses - version 9

- diagnostic coding system used by most countries to classify patient diagnoses

21
Q

PPS

A
  • 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
22
Q

DRG

A
  • 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.
23
Q

Acute (Hospital)

A

-“regular” hospital bed, includes intensive care units

24
Q

IRF

A
  • 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
25
Q

SNF

A
  • 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
26
Q

LTC

A
  • long term care facility
  • “nursing home”
  • residential facility for people who can no longer care for themselves at home
27
Q

AL / IL

A
  • 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
28
Q

HHA

A
  • home health agency

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

29
Q

OP

A
  • 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]