Test 1 Flashcards

1
Q

For Profit Organization

A

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

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2
Q

Not-For-Profit Organizations

A

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

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3
Q

Deductable

A

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

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4
Q

Copay

A

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

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5
Q

Coinsurance

A

the percentage of the total cost that the patient must pay

normally ranges from 10-20%

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6
Q

Private vs Public Insurance

A

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

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7
Q

Fee For Service (FFS)

A

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

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8
Q

PPO (Preferred Provider Organization)

A

. providers sign contracts governing payment

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

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9
Q

Health Maintenance Organization (HMO)

A

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

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10
Q

Consumer Directed Health Plan (CDHP)

A

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

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11
Q

High Deductible Health Plan (HDHP)

A

. a plan with a higher than normal deductible

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12
Q

Explanation of Benefits (EOB)

A

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

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13
Q

Allowable

A

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

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14
Q

CPT-4

A

. current procedural terminology- version 4

. the various codes used for billing

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15
Q

ICD-10

A

. International Classification o Diagnoses- version 10

. coding system used to classify patient diagnoses

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16
Q

Prospect Payment System (PPS)

A

. provider knows what will be paid ahead of time

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

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17
Q

Diagnosis Related Group (DRG)

A

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

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18
Q

Inpatient Rehab Facility (IRF)

A

. 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

19
Q

Skilled Nursing Facility (SNF)

A

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

20
Q

Long Term Care (LTC)

A

. for those that can no longer take care of themselves

21
Q

Home Health Agency (HHA)

A

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

22
Q

Outpatient Services (OP)

A

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

23
Q

Fee Schedule

A

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

24
Q

Capitation

A

. 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

25
Types of Financial Risk
Demand: how many people seek out service (more = increased risk) Volume: Type, Quantity, and LOS
26
Discounted FFS
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
27
Per Diem
paid per visit whether it is 10 min or 90 | payer (demand) and provider (volume) are at risk
28
Inpatient Per Diem
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
29
Case Rates
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
30
DRG
case rate for acute inpatient hospital units | provider at risk for LOS possibilities
31
Bundled Payment
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
32
Risk Profile
FFS, DFFS, Per Diem/Visit, Case Rate/DRG, Capitation risk increased for provider and decreases for insurer and we move left to right
33
Medicare
for people over the age of 65
34
Medicaid
for those who can't afford health care
35
Claim
the payment that is due for services provided
36
Global Capitation
incentives for prevention and for patient not to use services
37
Classes of Payment Plans
Conventional: FFS, Indemnity, Deductible, Coinsurance | Managed Care Plans: PPO (DFFS); HMO (PCP Gatekeepers);
38
HMO Staff Model
providers can only see patients from their HMO | physician works for HMO
39
Group Model HMO
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.
40
Network HMO
physicians do not work for HMO but receive reimbursements from it capitation payment
41
IPA HMO
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
42
Point of Service HMO
allows patients to get care out of network for higher premium and copay more expensive for patients
43
Managed Care Continuum
as employee freedom increases medical cost control decreases | as medical cost control rises, employee freedom of choice decreases