04: Cost Containment Flashcards
(38 cards)
The potential to lose money, earn less, or spend more time without additional payment on a reimbursement transaction is known as…
Risk
This reimbursement type is characterized by the party paying the bill (e.g., insurance company, government agency, or patient) being the one who absorbs all the risk.
Fee for service (FFS)
This reimbursement type is characterized by a portion of the risk being shared between payer and provider.
Bundle services
Which unit of payment for services is characterized by “payment per visit or procedure” and has the incentive to provide more services to bring greater revenue?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
A
Which unit of payment for services is characterized by “one payment made for each patient per month (or year)”?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
D
Which unit of payment for services is characterized by “physician is paid one lump sum for all services delivered during an episode of illness” and has the incentive to limit the number of visits?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
B
Which unit of payment for services is characterized by “payment per visit/procedure” and has the incentive to provide more services to bring greater revenue for the visit/procedure?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
C
Which unit of payment for services is characterized by “facility is paid for all services delivered to a patient in 1 day”?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
C
Which unit of payment for services is characterized by “includes a global budget payment of hospitals and salaried payment of physician (lump sum) per ‘X’ period” and has the incentive to provide more services to bring greater revenue?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
E
The usual, customary, and reasonable system (UCR) allowed physicians what?
Flexibility in their fees
What did the resource-based relative-value scale (RBRVS) do?
Created a fee schedule by “area” (like in a PPO)
Roy sees his physician for a recent onset of diabetes. The physician spent 20 minutes on the exam ($92), finger stick blood glucose ($8), urinalysis ($15), and ECG ($70). Because Roy has no insurance, the physician reduced the bill from $185 to $90.
This demonstrates what construct of FFS?
Usual, Customary, and Reasonable system (UCR)
A physician is contracted with Blue Cross to care for its PPO at 70% of his normal fee. Rick, a PPO patient, comes in with a severe headache and weakness in his right arm. The Physician sees him for 20 minutes at a fee of $100. The Physician gets paid $70 from PPO.
This demonstrates what construct of FFS?
Resource-Based Relative-Value Scale (RBRVS)
Dr. Brett removes Larry’s gallbladder and is paid $1300 by Blue Cross. Besides performing the surgery, he sees Larry three times in the hospital and twice in his office for post-operative visits. He cannot bill separately for visits, so $1300 covers everything.
What unit of payment is described here?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
B
Carve-outs and Risk Adjusted are two types of which unit of payment?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
D
True or false: A carve-out is typically paid on a FFS basis for services not covered by capitation.
True
Which is more common in the United States, a Two-Tiered Capital system, or Three-Tiered?
Three-tiered
What are the three tiers of the US capitation system?
- PCP gets a capitation or FFS for services, and can refer for specialty services
- IPA (independent practice association) pays for referral service for specialty services
- Extra money at the end of the year comes as a bonus to PCP (incentive for decreased referrals and diagnostics)
Mr. Lee goes to the hospital for a bleeding ulcer. At the end of a 4-day stay, the hospital sent a $14,000 seven-page itemized bill to the insurance company for payment.
What unit of hospital payment is described here?
A. Payment per diem
B. Payment per procedure
C. Payment per episode
D. Payment per patient
B
Upscale hospital is paid a fixed payment for all hospital services for 1 year.
What unit of hospital payment is described here?
A. Payment per diem
B. Payment per procedure
C. Payment per episode
D. Payment per patient
E. Payment per institution
E
Jane is enrolled in Blue Cross HMO, which contracts with Upscale Hospital to care for Jane’s hospitalization. Upscale receives $60 a month as a capitation fee from the HMO. Jane is healthy and during the 36 months she is an HMO member, the hospital receives $2160 even though she has never been to the hospital.
What unit of hospital payment is described here?
A. Payment per diem
B. Payment per procedure
C. Payment per episode
D. Payment per patient
E. Payment per institution
D
Upscale hospital is paid a fixed payment for all hospital services for 1 year.
What unit of hospital payment is described here?
A. Payment per diem
B. Payment per procedure
C. Payment per episode
D. Payment per patient
E. Payment per institution
E
Fee for service with utilization review (UR), preferred provider organizations (PPO), and health maintenance organization (HMO) are all examples of what kind of healthcare plan?
Managed care plan
Which of the following is not a value-based payment plan?
A. Pay per episode
B. Pay per performance
C. Bundled payments
D. Care coordination payments
E. Accountable care organizations
A
