Test 1 Flashcards
For Profit Organization
all profits generated from enterprise can be paid to shareholders
have to pay property and sales taxes
Ex: UHC, Aetna, HCA, Private Practice
Not-For-Profit Organizations
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
Deductable
amount the patient must reach each year before insurer starts to pay
all cost is on patient until that number is reached
Copay
what the patient pays at the time of service (even after deductable is met)
is a fixed amount
Coinsurance
the percentage of the total cost that the patient must pay
normally ranges from 10-20%
Private vs Public Insurance
private entities are non-government funded while public are
Private: Humana, BCBS, UHC
Public: medicare, medicaid, Tri-care
Fee For Service (FFS)
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
PPO (Preferred Provider Organization)
. providers sign contracts governing payment
. insurers offer low premiums, but restrict where their patient can go for care (out of state?)
Health Maintenance Organization (HMO)
. was successful in reducing cost of premiums and healthcare
. has a lack of patient freedom/choice
. PCP has responsibility due to capitation
Consumer Directed Health Plan (CDHP)
. is a combination of a Medical Saving Account (MSA), and a high deductible health plan
. risk is on the patient
High Deductible Health Plan (HDHP)
. a plan with a higher than normal deductible
Explanation of Benefits (EOB)
. defines the allowable OR what the insurer will pay and what the patient then owes the provider
Allowable
. the total amount the provider is paid per contract with insurer
. includes deductibles, copays, coinsurance, insurer payment
CPT-4
. current procedural terminology- version 4
. the various codes used for billing
ICD-10
. International Classification o Diagnoses- version 10
. coding system used to classify patient diagnoses
Prospect Payment System (PPS)
. provider knows what will be paid ahead of time
. provider could charge more, but they will still only get set amount
Diagnosis Related Group (DRG)
. provider receives a flat rate for length of stay no matter how many/few services are provided
Inpatient Rehab Facility (IRF)
. 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
Skilled Nursing Facility (SNF)
. post-acute for those in need of continued care
. 3+ hours of rehab a day
. patient may not return home
Long Term Care (LTC)
. for those that can no longer take care of themselves
Home Health Agency (HHA)
. provides post-acute services (PT, nursing) for the homebound
Outpatient Services (OP)
. wide range of pre/post-acute services provided by a lot of different professionals
Fee Schedule
. prices are set for a particular CPT code
. this is agreed upon
. encourages provider to bill for the higher paying code
Capitation
. 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
Types of Financial Risk
Demand: how many people seek out service (more = increased risk)
Volume: Type, Quantity, and LOS
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
Per Diem
paid per visit whether it is 10 min or 90
payer (demand) and provider (volume) are at risk
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
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
DRG
case rate for acute inpatient hospital units
provider at risk for LOS possibilities
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
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
Medicare
for people over the age of 65
Medicaid
for those who can’t afford health care
Claim
the payment that is due for services provided
Global Capitation
incentives for prevention and for patient not to use services
Classes of Payment Plans
Conventional: FFS, Indemnity, Deductible, Coinsurance
Managed Care Plans: PPO (DFFS); HMO (PCP Gatekeepers);
HMO Staff Model
providers can only see patients from their HMO
physician works for HMO
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.
Network HMO
physicians do not work for HMO but receive reimbursements from it
capitation payment
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
Point of Service HMO
allows patients to get care out of network for higher premium and copay
more expensive for patients
Managed Care Continuum
as employee freedom increases medical cost control decreases
as medical cost control rises, employee freedom of choice decreases
