vocabulary

Question 1

actual charge

Answer 1

The provider’s bill or submitted charge

Question 2

advanced beneficiary notice (ABN)

Answer 2

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

Question 3

Allowable charge

Answer 3

The maximum fee a third party payer will reimburse a provider for a given service. Usually specified on a “fee schedule”

Question 4

capitation

Answer 4

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

Question 5

case management

Answer 5

care coordinated by a case manager (usually a nurse or social worker)

Question 6

who is a case manager?

Answer 6

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

Question 7

who is an external case manager?

Answer 7

employed by a managed care company in order to control costs, length of stays & best outcome

Question 8

what is catastrophic health insurance?

Answer 8

insurance that provides protection against the high cost of treating severe, lengthy illnesses or disabilities

Question 9

what are clinical pathways?

Answer 9

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

Question 10

co-payment

Answer 10

Component of a health insurance plan that requires a client to pay a % of the cost

Question 11

deductible

Answer 11

The amount that an individual must pay before an insurer assumes liability

Question 12

diagnostic codes

Answer 12

Categories of medical conditions used for reimbursement

Question 13

diagnostic related groups (DRG)

Answer 13

Classifications of illnesses and injuries used as the basis for prospective payment under Medicare and other insurers in acute care

Question 14

durable medical equipment

Answer 14

(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

Question 15

essential health benefits

Answer 15

package of benefits that the federal government requires must be offered by ACOs.

Question 16

what are the 10 categories of essential health benefits?

Answer 16

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)

Question 17

fee for service

Answer 17

Payment method by which provider is reimbursed for each service/encounter

Question 18

gatekeeper

Answer 18

primary care physician who is responsible for coordinating one’s medical care and referrals

Question 19

health maintenance organization

Answer 19

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

Question 20

how can patient with health maintenance organization insurance receive specialty care?

Answer 20

utilization reviews of services is coordinated by the HMO primary care physician, who must see a patient before a patient can obtain specialty care

Question 21

what is a “pure” form of managed care?

Answer 21

health maintenance organization insurance

Question 22

managed care

Answer 22

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

Question 23

what are examples of managed care options?

Answer 23

HMOs, PPOs, and POS plans with varying degrees of restriction

Question 24

medicaid

Answer 24

joint federal-state program providing heath care to the poor and medically needy populations

Question 25

what are the categories of medicaid?

Answer 25

mandatory and optional

Question 26

medicare

Answer 26

federal program providing health insurance coverage for those >65 years of age, persons with ESRD, and persons with disabilities

Question 27

what are the 4 programs of medicare?

Answer 27

Part A , B, C (aka Medicare Advantage) and Part D

Question 28

medicare advantage programs

Answer 28

Medicare Advantage Plan (like an HMO or PPO) is Medicare health plan choice offered by private companies approved by Medicare; AKA Managed Medicare plans

Question 29

medicare gap policy

Answer 29

secondary insurance that beneficiaries purchase to cover costs that Medicare does not pay for;

Question 30

how do people with medicare gap policy receive funds?

Answer 30

bills must be submitted to Medicare before the secondary insurance will pay

Question 31

out of pocket cost

Answer 31

Costs paid by the patient without the benefit of insurance

Question 32

pay for performance

Answer 32

(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

Question 33

point of service (POS) plan

Answer 33

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

Question 34

practice profiling

Answer 34

development of provider specific practice patterns and the comparison of individual practice patterns to some norm

Question 35

per diem rate

Answer 35

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

Question 36

pre-certification

Answer 36

Requirement that specific procedures or categories of services be authorized before they are provided

Question 37

why is pre-certification done?

Answer 37

Gives the insurer the opportunity to deny unnecessary services” or substitute lower costs services. AKA preauthorization

Question 38

preferred provider organization (PPO)

Answer 38

network of medical care providers and facilities that agree to discount their charges in return for a high volume of patients

Question 39

procedure codes

Answer 39

Codes that specify services performed by a health care provider.

Question 40

what are the most common procedure codes?

Answer 40

“CPT” codes are the most common type of procedure codes and they provide uniform terminology for thousands of medical procedures

Question 41

prospective payment

Answer 41

Payment for care based on a specific type of injury or illness amount paid is predetermined

Question 42

what is prospective payment based on?

Answer 42

based on the “average” expense for a particular condition

Question 43

third party payer

Answer 43

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

Question 44

utilization review

Answer 44

process of evaluating the appropriateness of services provided. Can be done prospectively, concurrently or retrospectively

Question 45

value based purchasing (VBP)

Answer 45

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

Question 46

what is an advantage of PPO’s?

Answer 46

Patients who use PPOs often have little out of pocket expenses