vocabulary Flashcards
actual charge
The provider’s bill or submitted charge
advanced beneficiary notice (ABN)
Under Medicare, a notice a health care provider gives to a
beneficiary to sign when the provider believes Medicare will not pay for the service being rendered
Allowable charge
The maximum fee a third party payer will reimburse a provider for a given service. Usually specified on a “fee schedule”
capitation
A method of payment which provider receives fixed-pre-paid amount for each individual enrolled in the health plan; the provider assumes responsibility for all health care services
case management
care coordinated by a case manager (usually a nurse or social worker)
who is a case manager?
works for the health care provider and their role is to explain the need for services; acts as a liaison between the provider and the external case manager
who is an external case manager?
employed by a managed care company in order to control costs, length of stays & best outcome
what is catastrophic health insurance?
insurance that provides protection against the high cost of treating severe, lengthy illnesses or disabilities
what are clinical pathways?
Tx plan or regime made by heath care providers for a particular diagnosis or procedure
made to minimize delays in tx and resources and to maximize outcomes.
AKA: critical pathways, care maps; AKA clinical practice guidelines
co-payment
Component of a health insurance plan that requires a client to pay a % of the cost
deductible
The amount that an individual must pay before an insurer assumes liability
diagnostic codes
Categories of medical conditions used for reimbursement
diagnostic related groups (DRG)
Classifications of illnesses and injuries used as the basis for prospective payment under Medicare and other insurers in acute care
durable medical equipment
(defined by Medicare)
equipment used in the home, withstands repeated use, used to serve a medical purpose and not useful to a person without illness or injury
essential health benefits
package of benefits that the federal government requires must be offered by ACOs.
what are the 10 categories of essential health benefits?
ambulatory patient services emergency services hospitalization maternity + newborn care mental + substance use services (behavioral health treatment) prescriptions rehab services and devices laboratory services preventive wellness + chronic disease management pediatric services (oral + vision care)
fee for service
Payment method by which provider is reimbursed for each service/encounter
gatekeeper
primary care physician who is responsible for coordinating one’s medical care and referrals
health maintenance organization
insurance that provides health care with members prepaying a fixed amount to receive all required medical care
Highest Financial risk to providers. various kinds of HMOs, e.g. group model, staff model, network model
how can patient with health maintenance organization insurance receive specialty care?
utilization reviews of services is coordinated by the HMO primary care physician, who must see a patient before a patient can obtain specialty care
what is a “pure” form of managed care?
health maintenance organization insurance
managed care
generic term used for types of integrated health delivery systems implying that they “manage” the care received by consumers
sometimes referred to as coordinated care
what are examples of managed care options?
HMOs, PPOs, and POS plans with varying degrees of restriction
medicaid
joint federal-state program providing heath care to the poor and medically needy populations
what are the categories of medicaid?
mandatory and optional
medicare
federal program providing health insurance coverage for those >65 years of age, persons with ESRD, and persons with disabilities
what are the 4 programs of medicare?
Part A , B, C (aka Medicare Advantage) and Part D
medicare advantage programs
Medicare Advantage Plan (like an HMO or PPO) is Medicare health plan choice offered by private companies approved by Medicare; AKA Managed Medicare plans
medicare gap policy
secondary insurance that beneficiaries purchase to cover costs that Medicare does not pay for;
how do people with medicare gap policy receive funds?
bills must be submitted to Medicare before the secondary insurance will pay
out of pocket cost
Costs paid by the patient without the benefit of insurance
pay for performance
(P4P) Reimbursement based on the quality and efficiency of service. In P4P, rewards are given to providers who improve health outcomes while using resources frugally.
P4P uses performance benchmarks as parameters of structure, process, or outcome metrics, whose attainment defines good quality care
point of service (POS) plan
managed care plan that allows members to decide at the time they need medical care (the point of service) whether to go to a provider on the panel or pay more and go out of the network.
Co-payments are higher if patient goes outside the network
practice profiling
development of provider specific practice patterns and the comparison of individual practice patterns to some norm
per diem rate
fixed all inclusive price for one day of care; includes all supplies and services provided during a day with the except of professional fees for non-staff physicians
pre-certification
Requirement that specific procedures or categories of services be authorized before they are provided
why is pre-certification done?
Gives the insurer the opportunity to deny unnecessary services” or substitute lower costs services. AKA preauthorization
preferred provider organization (PPO)
network of medical care providers and facilities that agree to discount their charges in return for a high volume of patients
procedure codes
Codes that specify services performed by a health care provider.
what are the most common procedure codes?
“CPT” codes are the most common type of procedure codes and they provide uniform terminology for thousands of medical procedures
prospective payment
Payment for care based on a specific type of injury or illness amount paid is predetermined
what is prospective payment based on?
based on the “average” expense for a particular condition
third party payer
Any payer for health care services other than the individual receiving the care. a group that pays or insures health and medical expenses for a beneficiary
utilization review
process of evaluating the appropriateness of services provided. Can be done prospectively, concurrently or retrospectively
value based purchasing (VBP)
Links provider payments to improved performance by health care providers.
holds health care providers accountable for cost and quality of care they provide in order to reduce inappropriate care and to identify and reward the best-performing providers
what is an advantage of PPO’s?
Patients who use PPOs often have little out of pocket expenses
