Week 1; Chapters 11: The Blue Plans, Private Insurance, and Managed Care Plans/ Chapter 12: Medicare Flashcards
The Blue Cross/Blue Shield Association petitioned and was allowed to convert their status from a non-for-profit organization to a for-profit organization in the year
1994
The name and address of the BCBS home company that should be used for claims submission can be found on the
identification card
What refers to a group of techniques intended to offset the cost of providing health care while improving the access to care and the quality of care?
Managed care
Define fee-for-service
a method of payment in which the patient pays the physician for each professional service performed from an established schedule of fees.
Define a fee schedule
a list of charges or established allowances for specific medical services and procedures. see also relative value studies (RVS)
Define relative value studies
it is list of procedure codes for professional services and procedures that are assigned unit values that indicate the relative value of one procedure over another
Define ancillary services
it is a supportive services other than routine hospital services provided by the facility, such as x-ray films and laboratory tests
Define buffering
it is a physician’s justifying the transference of sick, high-cost patients to other physicians in a managed care plan.
Define Capitation
is a system of payment used by managed care plans in which physicians and hospitals are paid a fixed per capita amount for each patient enrolled over a stated period of time, regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan. Capitation can also mean a set amount to be paid per claim.
Define Advanced Beneficiary notice of Noncoverage (ABN)
An agreement given to the patient to read and sign before rendering a serice if the participating physician thinks it may be denied for payment because of medical neccesity or limitation of liability by Medicare. The patient agrees to pay for the service; also known as a waiver of liabilty agreement or responsibility statement.
Define Approved charges
is a fee that Medicare decided the medical service is worth, which may or may not be the same as the amount billed. The patient may or may not be responsible for the difference.
Define assignment
Its a transfer after an event insured against or an individual’s legal right to collect to collect an amount payable under an insurance contract. When related to medicare, this an agreement in which a patient assigns the right to recieve payment from the medicare administrative contractor to the physician. Under this agreement, the physician must agree to accept 80% of the allowed amount as payment in full once the deductible has been met. For TRICARE, providers who accept assignement agree to accept 75% or 80% of the TRICARE allowable charge as the full fee, collecting the deductible and 20% or 25% of the allowable charge from the patient. With 25% of the allowable charge from the patient. With other carries, accepting assignement means that in return for payment of the claim, the provider accepts the terms of the contract between the patient and carrier.
Define benefit period
- it is a period of time during which payments for Medicare inpatient hospital benefits are available. A benefit period begins on the first day enrollee is given inpatient hospital care (nursing care or rehabilitation services) by a qualified provider and ends when the enrollee has not been an inpatient for 60 consecutive days. 2. In workers compenstaion cases, the maximum amount of time that benefits wil be paid to the injured or ill person for the disability. 3. For disablilty insurance, the maximum amount of time that benefits will be paid to the injured or ill person for a disability.
Define Buffering
it is a physician’s justifying the transference of sick, high-cost patients to other physicians in a managed care plan.
Define Capitation
it is a system of payment used bymanaged care plans in which phhysicians and hospitials are paid a fixed per capita amount for each patient enrolled over a stated period of time, regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month bais to cover costs for the members of the plan. Capitation can also mean a set amount to be paid per claim.
Define Carve outs
medical service not included within the capitation rate as benefits of a managed care contract and that may be contracted for seperately.
Centers for Medicare and Medicaid Services (CMS)
formerly known as the Health Care Financing Administration (HCFA), CMS divides responsibilites among three divisions: the Centers for Medicare Management the Center for Beneficiary Choices, and the Center for Medicaid and Stated Operations.
Churning
is when physicians see a high volume of patients-more than medically necessary-to increase revenue. May be seen in fee-for-service or managed care environments
Claims-review type of foundation
is a type of foundation that provides peer review by physicians to the numerious fiscal agents or carriers involved in its area.
closed panel program
is a form of health maintenance organization (HMO) that limits the patient’s choice of personal physicians to only those doctors practocong in the HMO group practice within the geographis location or facility. A physician must meet narrow criteria to join a closed panel.
Comprehensive type of foundation
is a type of foundation that designs and sponsor prepaid health programs or sets minimum benefits of coverage.
what is a copayment or copay
- A patient’s payment (for example, 20% of a bill or a flat fee of $10 per visit) of a portion of the cost at the time service is rendered; sometimes referred to as coinsurance. 2. in the Medicaid program, a required specific dollar amount that must be collected at each office visit for medical services recieved by an individua. Different copayment amounts may be set for each patient type and for certain medical procedures
What is a cross over claim
is it a bill for services rendered to a patient recieving benefits simultaneously from medicare and medicaid or from medicare and a medigap plan. Medicare pays first and then determines the amount of unmet Medicare deductible and coinsurance to be paid by the secondary insurance carrier for additional payment. Also known as claims transfer.
What is a deductibl
it is aspecific dollar amount that must be paid by the insured before a medical insurance plan or government program begins covering health care costs.
