Test 2 Flashcards
What is considered long term health care?
Care that lasts for more than 90 days
Basic activities such as mobility, eating, toileting, dressing and bathing
ADL
Activities like managing money, telephoning, grocery shopping, personal shopping, using transportation, and housekeeping and managing medication
Instrumental activities of daily living
Authorizes federal grants for construction of public or nonprofit community mental health centers
Community mental health act of 1963
Requires group health plans and health insurance issuers to ensure that financial requirements and treatment limitations applicable to mental health or substance use disorder
Parity Act of 2008
Hospitals and primary physicians would transform their practices financially, technologically, and clinically to drive better health outcomes, lower costs, and improve their methods of distribution and accessibility.
Affordable care act
Ability to cope with a change, a positive outlook on life, ability to interact in close relationships in a loving and supportive manner, and the general feeling of well-being that can be assessed in the individual
Mental Health
Provides a product or service to customers for a profit
Business
Profit is the primary reason for the business to exist
For-profit
Something other than profit is the main objective; profits are invested back into the business, often to help the less fortunate
Non-profit
One person owns the business and makes all the decisions, and collects all of the profits
Sole Proprietorship
At least two individuals own the business and makes shared decision making, risk, and profits
Partnership
Each partner’s liability is limited to their contribution
Limited liability partnership
Separates ownership and management, shareholders own the business, but delegate management, risks&profits are limited to the shareholder’s investment
Corporation
Process of planning, organizing, directing, and controlling business’s resources to achieve the objectives
Management
Exchange process between a business and its customers
Marketing
Accounts receivable vs. accounts payable
Accounting
Process of physically creating the product or service
Production
Use of technology to manage information
Information technology
Use of electronic health records, recently laid off employees are eligible for a 9 month federal subsidy that covers 65% of premiums
American Recovery and Reinvestment act (ARRA) of 2009
Regulates portability, access, and mandated benefits, fraud, abuse, and reform of medical liability
HIPAA act of 1996
Based on supply/ demand, competition is key
Market economy
What two things make up profitability?
Revenue maximization and cost minimization
Evaluates and accredits health care organizations, focus on improvement of quality and safety of health care services, regulates competition through antitrust laws
Joint Commission
Created medicare and medicaid
1965 Social security act
Prohibits businesses from taking actions that lessens competition and prohibits mergers, monopolies, and price fixing/discrimination
Antitrust Laws
Prohibits restraint of trade and monopolization
Sherman Antitrust Act
Restrict practices such as price discrimination, exclusive dealing, and tying contracts
Clayton Act
Establishes federal trade commission to investigate business practices that are unfair
Federal trade commission act
Prohibits price discrimination, selling at unreasonably low prices to eliminate competition
Robison Patman act
Establishes food and drug administration; prohibits misbranding of food and drugs
Pure food and drug act
FDA given authority to regulate cosmetics and therapeutic products
Federal food, drug, and cosmetic act
Protects rights for people with disabilities
Americans with disabilities act
Process of combining all of those insured into one group so the group’s overall risk of loss is reduced
Risk pooling
Patient can only access certain services from primary care providers
Gatekeeping role
System of paying health care providers as well as delivering health care services
Managed Care
Managed care is regulated by….
State statute
Physicians are employees of the HMA and paid a salary
Staff model HMO
Physicians are employees of an independent group that contracts with the health plan to provide services
Prepaid group practice HMO
HMO contracts with at least two group practices to provide services
Netowork HMO
Physicians contract independently with the IPA to treat members of the HMO
Independent practice association HMO
Patient chooses his/her physician and hospital
PPO
Patient must select his/her care providers from those in network
EPO
What are the eligibility rules for medicare?
Over 65 years of age, permanently disabled, end-stage renal disease
Inpatient hospital services, critical access hospitals, skilled nursing facilities, limited and medically necessary home health care services and hospice
Part A medicare
Optional requiring monthly premiums, deductible and copayments
Part B
Offers a variety of manage care-type options to provide services under parts A and B
Part C
Replaced medicare+ choice with medicare advantage, coverage for prescriptions and preventative care
Part D
Reimbursement amount is determined prior to patient receiving services and is based on the patient’s classification into a diagnose related group
Prospective payment system
What is the eligibility for Medicaid?
Medically needed and poverty related
Eligible if receiving supplemental security incomes or temporary assistance for needy families
Poverty related
Applies to elderly pregnant women, children and persons with disabilities
Medically needy
State’s spending is matched by the federal government using the federal medical assistance percentage rate
Transfer program
What is covered in medicaid?
Hospital and physician services, pharmaceutical, dental care, eye care
Low income children whose parents do not qualify for medicaid but are unable to afford private health insurance
Stat children’s health insurance program
Covers federal employees, families, retirees and survivors
Federal employees health benefits program
Covers military personnel
TRICARE
Benefits are predetermined based on the type of injury and the amount of time the employee will be unable to work
Worker’s compensation
Plans work by assigning a fixed payment rate to specific treatments
Prospective payment system
Healthcare providers based on their actual charges.
Retrospective payment system
Accepted health care services and supplies provided by health care entities, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care.
Medical Necessity
Containing an additional 87,000 codes for use ONLY in United States inpatient, hospital settings
ICD-10-PCS
Codes were developed by the Centers for Disease Control and Prevention in conjunction with the National Center for Health Statistics (NCHS), for outpatient medical coding and reporting in the United States
ICD-10-CM
Used to determine how much Medicare pays the hospital
DRG
United States government’s method of paying for facility outpatient services for the Medicare
APC
Mutually exclusive categories that reflect levels of resource need in long-term care settings, primarily to facilitate Medicare and Medicaid payment
RUG
What you get after you pay premiums
Benefits
How much you pay each month
Premiums
