Unit 2- WK5- Reimbursement in Physical Therapy Practice Flashcards
What is the difference between prospective and retrospective payment ?
prospective payment: before services provided
retrospective payment: after services provided
What were the driving forces behind the Health Maintenance Organization Act ?
Increasing health care costs
increased control of delivery of healthcare through third party payers
What are the three tenants of managed care ?
Pre-determined payment schedule for covered services ( discounted fee schedule)
Provider Network: providers who sign a contract with insurance company and agree to payment schedule
Established MCOs, Restrict acccess to services by limiting the types, number, or payment for services provided
List and describe the 5 manage care provisions.
a. Pre-admission certification
prior authorization to determine treatment, including interventions
b. utilization management/review
assessment of services to patient; designed to decrease unnecessary services. Can be done before, during or after
c. Case management
cost control for patient with high cost medical conditions
case manager
d.CAPS
limit money amount per provider
e. Increased cost sharing.
Types of MCO’s: Health Maintenance Organization (HMO’s)
A health care system that assumes both the financial risks associated with providing comprehensive medical services ( insurance and service risk) and the responsibility for healthcare delivery in a geographic area to HMO members, usually in return for a fixed prepaid fee.
Subscriber sees a PCP, “ gatekeeper”, who coordinates all care including referrals for specialists
Types of MCO’s: Preferred Provider Organization (PPO)
An indemnity plan which provides coverage to participants through a network of in-network providers ( such as hospitals and physicians). The enrollees may go outside of network but would incur higher costs in the form of higher deductibles, higher coinsurance rates, or non-discounted charges from the providers.
Types of MCO’s: Exclusive Provider Organization ( EPO)
MORE RESTRICTIVE PPO PLAN
Employees must use providers from the specified network of providers to receive coverage.
No coverage for care received from a non-network provider except in an emergency situation.
Types of MCO’s: POS
HMO/PPO Hybrid
POS plans resemble HMOs for in-network services
Services received outside of network are usually reimbursed in a manner simliar to conventional indemnity plans
out of network providers= increased rate
Describe consumer driven health plans: High Deductible Health Plans
self explanatory…
Describe consumer driven health plans: Health Savings Account
a savings account that lets you set aside money on a pre-tax basis to pay for medical expenses
Describe consumer driven health plans: Health reimbursment arrangments
employer funded, employees are reimbursed tax free for medical expenses up to a fixed amount
Describe consumer driven health plans: Flexible spending accounts
an account used to pay for out of pocket medical costs; no taxes
limit of 2750 a year
Payment methodologies: Fee for service
each procedure (CPT) that is delivered is billed with a specified fee
fee schedule is based on price/unit of care
incentive for providers to deliver as many services as possible
Payment methodologies: Per-Visit ( Per Diem )
one lump sum of payment for each patient/client visit
little regard for the procedures delivered during the visit
incentive for providers to deliver fewer procedures/visits and more visits per episode
Payment methodologies: Per Episode
Single payment for all services delivered to a patient client for a given episode of care.
Payments are based on a pre-determined amount for that condition ( diagnosis code)
