Unit 2 Reimbursement in PT Practice Flashcards
Compare and Contrast Retrospective and Prospective methods of Payment
·Retrospective
·Prospective
·Retrospective: after services are provided; “fee-for-service” or indemnity plans; individual paid fee for health services provided; providers have little incentive to limit services or costs
·Prospective: before services are provided; payments are established before care is provided; fees and services covered are set by insurance companies; these amounts are paid regardless of the costs they actually incur; health care choices are being influences by insurance companies
What were the driving forces behind The Health Maintenance Organization Act?
to increase the control of the delivery of health care by 3rd party payers through government-mandated regulations of health care service
Three Tenants of Managed Care
·__________________ payment schedule for covered services (discounted fee schedule)
·__________________: Providers who sign a contract with insurance company and agree to the payment schedule
·Established managed care organizations (MCOs) Restrict access to services by limiting the __________, _______________, or ______________________
·predetermined
·provider network (panel)
·types of, number or, or payment for services covered
List and describe the 5 manage care provisions (features within health plans that provide insurers with a way to manage the cost, utilization, and quality of health care services received by members)
-pre-admission certification: pre authorization
-utilization management/review: assessment of medical necessity, appropriateness, and reasonableness of services
-case management: cost-control process
-maximum plan dollar limit (caps)
-increased cost-sharing
Health Maintenance Organization (HMO)
*A health care system that assumes both the ________________ associated with providing comprehensive medical services (insurance and service risk) and the responsibility for _____________________________ _____________________________ to HMO members, usually in return for a fixed, prepaid fee
*Subscriber sees a PCP, “_______________”, who coordinates all care including referrals for specialists
*financial risks; health care delivery in a particular geographic area
*“gatekeeper”
Preferred Provider Organization (PPO)
*An indemnity plan which provides coverage to participants through a ______________________________________ (such as hospitals and physicians). The enrollees may go outside the network but would incur _______________________ in the form of higher deductibles, higher coinsurance rates, or non-discounted charges from the providers.
*network of selected health care providers; larger costs
Exclusive Provider Organization (EPO)
*More restrictive PPO plan
*Employees must use providers from the __________________________ ____________________________ to receive coverage
*_______________________ for care received from a non-network provider except in an emergency situation
*specified network of physicians and hospitals
*no coverage
Point of Service (POS)
*HMO/PPO _________________
*POS plans resemble HMOs for __________________ services.
*Services received _____________________________ are usually reimbursed in a manner similar to conventional indemnity plans (provider reimbursement based on a fee schedule or usual, customary, and reasonable charges
*hybrid
*in-network
*by out of network providers are covered, but at a higher rate
Describe Consumer-Driven Health Plans
·High Deductible Health Plans
·Health Savings Accounts
·Health Reimbursement Arrangements
·Flexible Spending Accounts
-combines employer contributions with increased employee choice and responsibility and increased health plan and provider accountability
·high deductible health play with a personal or HSA: lower premiums and higher deductibles
·HSA: savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses
·HRA: employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year
·FSA: a special account you put money into that you use to pat for certain out-of-pocket health care costs
Fee-for-Service
*Each procedure (CPT) that is delivered is billed with a __________________
*______________________ is based on price/unit of care
*Incentive for providers to deliver as many ___________________________
*specified fee (CPT codes)
*fee schedule
*services as possible
Per-Visit (Per Diem)
*_____________________________________ for each patient/client visit
*Little regard for the ________________________ delivered during the visit
*Incentive for providers to deliver ____________________________ and more visits per episode
*one lump sum payment
*specific type of procedures
*fewer procedures per visit
Per Episode
*Single payment for all services delivered to a patient/client for a given _________________________
*Payments are based on a ______________________________ for that condition (diagnosis code)
*episode of care
*predetermined fixed amount
Capitation
*_________________________ each month for all the covered subscribers for which the provider is responsible
*Payment is the same regardless ___________________________provided or volume of patients seen
*fixed, pre-arranged payment
*of the number of interventions
Multiple Procedure Payment
*Subsequent procedures performed during the same session by the same provider are ________________ usually by a percentage of the allowable amount
*Payer will __________________________ by the number of units billed
*reduced
*reduce payment
What are the objectives of Pay for Performance programs? How is the provider reimbursed for services rendered?
-improve the quality, efficiency, and overall value of health care by linking payment to value of care
-based on a matric of desired outcome: meet or exceed agreed-upon quality or performance get financially rewarded
