Prof quiz 3 hints, part 2 Flashcards
Reimbursement definition
Determination of methods and amounts of reimbursement in advance of delivery
Disbursement defintion
Actual payment after services have been rendered
Charge definition
A price set by provider
Rate definition
A price set by a 3rd party payer
Fee schedule definition
An index of charges listing individual fees for each type of svc
Aspects of fee for svc
The oldest method
Charges are set by the provider
Each svc billed separately
Later insurers adopted UCR (usual, customary and reasonable) charge
Main drawback is provider-induced demand
Aspects of capitation
Per member per month (PMPM) fee to cover all needed svcs
Monthly fee = PMPM rate x number of enrollees
Minimizes provider induced demand and promotes prudence
Aspects of outpatient care as compared to ambulatory care
More comprehensive
Outpt svcs: any HC svcs that are not provided on the basis of an overnight stay in which room and board are incurred
Aspects of ambulatory care as compared to outpt care
Care rendered to the “walking” (ambulatory) pts who come to the physician office, clinics, or outpt surgery
Diagnostic and therapeutic
Mobile diagnostic units and home health
Take svcs to pts
Aspects of primary care in terms of outpt vs ambulatory
The foundation for ambulatory care
All primary care is outpt
Not all outpt care is primary care
Reasons for growth in outpt svcs
Changes in reimbursement
Fewer payment restrictions
Development of new tech
Utilization controls by managed care
Social factors
Trends in changes in reimbursement for outpt svcs
Constraining inpt svcs
Favoring outpt svcs
Where are there fewer payment restrictions in outpt svcs?
Surgery, dialysis, chemotherapy
Paid as fee for service
Developments in new tech for outpt- what do they result in?
Less invasive procedures
Quicker recuperation from surgery
How have utilization controls by managed care affected outpt growth?
Restriction on utilization, quicker d/c
-Prior auth
-Utilization review
