Test 1

Question 1

For Profit Organization

Answer 1

all profits generated from enterprise can be paid to shareholders
have to pay property and sales taxes
Ex: UHC, Aetna, HCA, Private Practice

Question 2

Not-For-Profit Organizations

Answer 2

all profits generated are put back into the business
does not have to pay property and sales taxes
Ex: most hospitals, BSBS, some nursing homes

Question 3

Deductable

Answer 3

amount the patient must reach each year before insurer starts to pay
all cost is on patient until that number is reached

Question 4

Copay

Answer 4

what the patient pays at the time of service (even after deductable is met)
is a fixed amount

Question 5

Coinsurance

Answer 5

the percentage of the total cost that the patient must pay

normally ranges from 10-20%

Question 6

Private vs Public Insurance

Answer 6

private entities are non-government funded while public are
Private: Humana, BCBS, UHC
Public: medicare, medicaid, Tri-care

Question 7

Fee For Service (FFS)

Answer 7

provider bills insurer and they pay for it
put the risk on the insurer
incentivizes docs. to do more in order to get paid more

Question 8

PPO (Preferred Provider Organization)

Answer 8

. providers sign contracts governing payment

. insurers offer low premiums, but restrict where their patient can go for care (out of state?)

Question 9

Health Maintenance Organization (HMO)

Answer 9

. was successful in reducing cost of premiums and healthcare
. has a lack of patient freedom/choice
. PCP has responsibility due to capitation

Question 10

Consumer Directed Health Plan (CDHP)

Answer 10

. is a combination of a Medical Saving Account (MSA), and a high deductible health plan
. risk is on the patient

Question 11

High Deductible Health Plan (HDHP)

Answer 11

. a plan with a higher than normal deductible

Question 12

Explanation of Benefits (EOB)

Answer 12

. defines the allowable OR what the insurer will pay and what the patient then owes the provider

Question 13

Allowable

Answer 13

. the total amount the provider is paid per contract with insurer
. includes deductibles, copays, coinsurance, insurer payment

Question 14

CPT-4

Answer 14

. current procedural terminology- version 4

. the various codes used for billing

Question 15

ICD-10

Answer 15

. International Classification o Diagnoses- version 10

. coding system used to classify patient diagnoses

Question 16

Prospect Payment System (PPS)

Answer 16

. provider knows what will be paid ahead of time

. provider could charge more, but they will still only get set amount

Question 17

Diagnosis Related Group (DRG)

Answer 17

. provider receives a flat rate for length of stay no matter how many/few services are provided

Question 18

Inpatient Rehab Facility (IRF)

Answer 18

. post-acute facility for those in need of intensive rehab
. 3+ hours of PT, OT, SLP a day; 5 days a week
. patient should have potential to return home

Question 19

Skilled Nursing Facility (SNF)

Answer 19

. post-acute for those in need of continued care
. 3+ hours of rehab a day
. patient may not return home

Question 20

Long Term Care (LTC)

Answer 20

. for those that can no longer take care of themselves

Question 21

Home Health Agency (HHA)

Answer 21

. provides post-acute services (PT, nursing) for the homebound

Question 22

Outpatient Services (OP)

Answer 22

. wide range of pre/post-acute services provided by a lot of different professionals

Question 23

Fee Schedule

Answer 23

. prices are set for a particular CPT code
. this is agreed upon
. encourages provider to bill for the higher paying code

Question 24

Capitation

Answer 24

. Insurer pays a flat rate per member per month no matter what services are provided
. docs. want to keep patients out so they don’t lose money

Question 25

Types of Financial Risk

Answer 25

Demand: how many people seek out service (more = increased risk)
Volume: Type, Quantity, and LOS

Question 26

Discounted FFS

Answer 26

contract between payer and provider creating an allowable that will be paid out
creates incentive for docs. to do more to get paid more
risk is on the payer

Question 27

Per Diem

Answer 27

paid per visit whether it is 10 min or 90

payer (demand) and provider (volume) are at risk

Question 28

Inpatient Per Diem

Answer 28

facility receives a daily rate for ALL services
incentivizes efficient care and team focused treatment
payer (no incentive to decrease LOS) and provider (daily reimbursement cap) at risk

Question 29

Case Rates

Answer 29

provider is given flat rate no matter what services provided during LOS
incentivizes efficient care
provider is at high risk and payer at low
provider takes all volume risk

Question 30

DRG

Answer 30

case rate for acute inpatient hospital units

provider at risk for LOS possibilities

Question 31

Bundled Payment

Answer 31

one provider is paid for the care provided by multiple providers
this provider then pays out to each other provider
incentivizes them to not continue care so they can keep more money
provider at risk due to sharing of volume

Question 32

Risk Profile

Answer 32

FFS, DFFS, Per Diem/Visit, Case Rate/DRG, Capitation

risk increased for provider and decreases for insurer and we move left to right

Question 33

Medicare

Answer 33

for people over the age of 65

Question 34

Medicaid

Answer 34

for those who can’t afford health care

Question 35

Claim

Answer 35

the payment that is due for services provided

Question 36

Global Capitation

Answer 36

incentives for prevention and for patient not to use services

Question 37

Classes of Payment Plans

Answer 37

Conventional: FFS, Indemnity, Deductible, Coinsurance

Managed Care Plans: PPO (DFFS); HMO (PCP Gatekeepers);

Question 38

HMO Staff Model

Answer 38

providers can only see patients from their HMO

physician works for HMO

Question 39

Group Model HMO

Answer 39

can see patients from insurers outside of their group
physician does not usually work for HMO
group practice is paid by capitation and they pay salary of docs.

Question 40

Network HMO

Answer 40

physicians do not work for HMO but receive reimbursements from it
capitation payment

Question 41

IPA HMO

Answer 41

entity that represents the physicians to the HMO, and receives part of their payment for it
allows providers to see patients from more than one HMO

Question 42

Point of Service HMO

Answer 42

allows patients to get care out of network for higher premium and copay
more expensive for patients

Question 43

Managed Care Continuum

Answer 43

as employee freedom increases medical cost control decreases

as medical cost control rises, employee freedom of choice decreases