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Semester 3 PID Exam 4 > 3rd Party Payers > Flashcards

3rd Party Payers Flashcards

1
Q

Charity Care

A

Pro Bono - low income level, no insurance

Financial assistance programs

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2
Q

Self Pay

A

No insurance
Does not qualify for charity/pro bono
May need payment plan
Might get discount if pay cash in full at time of service

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3
Q

Explanation of Benefits

A

Something that says what was done with medical procedure, what the insurance covered, and the write off

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4
Q

Medically Necessary

A

Must be reasonable, evidence based, standard of care

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5
Q

Hospital based service

A

an “outpatient” facility but it is associated with a hospital

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6
Q

NPI - National Provider Identifier

A

All outpatient PTs need an NPI - a medicare number that sticks with you and goes on all of your claims

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7
Q

Write off - contractual

A

Contract with insurance company that says they will pay a certain amount
Say 80 of the 100 so write off is 20

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8
Q

Traditional type of insurance organization

A

Indemnity plans - commercial insurance companies
All organized under state laws
Act as insurers, not providers

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9
Q

Managed Care - type of insurance organization

A

HMO
PPO
POS
EPO

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10
Q

HMO

A

In network

Gatekeeper to control/coordinate care

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11
Q

PPO

A

Contract btw health plan and provider
Encouraged to use specific providers
Can go out of network

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12
Q

POS

A

Hybrid PPO/HMO
Like an open ended HMO
PCP required
Can go out of network

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13
Q

EPO

A

Cross between HMO and PPO

In network care

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14
Q

High deductible health plan (HDHP)

A

Preventative care covered, other expenses must be paid until deductible met
Can be paired with a health savings account (HSA insurance plans) - then you can carry over

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15
Q

Workers Compensation

A

State regulated - employee directs provider or employee choice
Case manager frequently involved
Communication/documentation required for continued approval

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16
Q

Medicare/Medicaid

A

CMS - Centers for medicare and medicaid services

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17
Q

Medicare - parts

A 
A = hospital services
B = outpatient services
C = Medicare advantage plan 
D = outpatient prescriptions (private plans)
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18
Q

Tricare/Champus/VA

A

Health care program for uniformed service members, retirees, and their families
Military tx facilities vs civilian providers

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19
Q

Patient protection and affordable care act - Aims

A

Inc quality and affordability of health insurance
Lower uninsured rate
Contain rising costs

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20
Q

Patient protection and affordable care act - essential health benefits

A

9 essential health benefits

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21
Q

Patient protection and affordable care act - marketplaces

A

Providers qualified health plans (QHP) - 3 types - state based, partnership and federally facilitated

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22
Q

Qualified Health Plans

A

Cover the essential health benefits
Are modeled after states benchmark plan
Are subject to federal regulation and state insurance laws

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23
Q

Marketplace tips - Grace period

A

There is a grace period so it is important to check patient status
Adding a clause regarding nonpayment of health insurance premium to patient financial agreement is a good idea

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24
Q

Alternative payment methods

A

Accountable care organizations
Bundled payment models
Patient centered medical home

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25
Accountable care organizations (ACOs)
Network of health care providers agree to be accountable for quality, cost and overall care of medicare beneficiaries
26
ACOs - meet quality standards in four key areas
Patient/caregiver experiences Care coordination/patient safety Preventative health At risk population/frail elderly health
27
ACOs and PT
PTs can participate in an ACO but cannot create one
28
Bundled payment models
Bundled payment paid related to a treatment or conditions Used to encourage coordination among providers and promote efficient care Hospitals, physicians, and post acute care providers
29
Comprehensive Care for Joint Replacement - CJR
TKA, THA | Being tested for the next 5 years
30
Acute Care Episode - ACE
28 cardiac and 9 ortho inpatient surgical services and procedures jointly accountable for patient's care
31
Patient Centered Medical Homes (PCMH)
Primary care practices provide and coordinate patients care Community based health teams support primary care providers Prevention, care management for patients with chronic conditions Focus - managing care and directing medical care appropriately
32
Payment methods
Retrospective Payment Systems Prospective Payment Systems Pay for Performance
33
Retrospective Payment Systems
Fee for service/Fee schedule
34
Prospective Payment Systems
``` DRG RUG Per Diem Case Rate Capitation Multiple procedure payment ```
35
DRG
Diagnostic related group | Based on the diagnossi
36
RUG
Resource utilization group | Tiered payment depending on how patient presents and the service that may be needed
37
Per diem
per visit - set amount per patient per day
38
Case Rate
Per episode of care
39
Capitation
You are in agreement with insurance - you will get a set amount no matter what
40
Multiple procedure payment
scaled from private insurance
41
Pay for performance is based on
quality and outcomes of care
42
How are they covered? Acute Rehab
M, A, P
43
How are they covered? Acute Care
M, A, B, P
44
How are they covered? Pediatrics
M, P
45
How are they covered? SNF
M, A, B, P
46
How are they covered? OPT
M, B, P
47
How are they covered? Home care
M, A, B, P
48
Acute Care Hospital
Per Diem - private insurance FFS - fee for service Inpatient prospective payment system - DRG Med part A
49
Acute rehab/Rehab hospital/Inpatient Rehab Facility
Per Diem - private insurance IRF PPS (prospective payment system) Medicare - newer than DRG but same principle IRF PAI (need to fill out) 3 hour rule - 3 hrs of therapy 5 days a week
50
SNF
Per Diem - private insurance Case Mix - PPS - Med A Minimum Data set (MDS) RUGs - 5 levels (low to ultra high)
51
NH
Out of pocket | Medicaid
52
Home Health
``` PPS for medicare - need to fill out OASIS Must track minutes of PT Quality reporting Med B Private insurance ```
53
Outpatient Care
Third party payment - FFS, per visit, Case rate, Cpaitation, Med B, Work comp, employer contract/on site First party payment - self pay
54
Medicare physician fee schedule - Resource based relative value scale
Based on difficulty of work, practice expense, and malpractice expense
55
Schools
Provide services unter the individuals with disabiliteis in education act and the elementary and secondary education act Medicaid/childrens health insurance program - fed and state but state administers
56
Upcoding
Charging for more complex service
57
Unbundling
Billing separately for procedures that are covered by one fee
58
Examples of fraud
Upcoding, Unbundling Charging for services not provided Double billing Lack of medical necessity
59
Diagnosis determines reimbursement?
DRG | Acute Care
60
Paid for each service that is provided?
Outpatient | Fee for service
61
Accept negotiated rate for services for an episode of care?
Case rate, ACO, bundle payment | Outpatient or ACO
62
Payment based on patient classification which is tiered according to minutes?
RUG | SNF
63
Receive guaranteed monthly lump sum
Capitation | Outpatient

Semester 3 PID Exam 4 (3 decks)

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