Chapter 11 Flashcards
(46 cards)
1
Q
Revenue
A
income received as result of normal business activity
2
Q
Reimbursement
A
act of compensating someone for expenses incurred
3
Q
Worth
A
monetary units such as a salary; price paid for something
- relatively static
4
Q
Value
A
- tangible & intangible
- may increase or decrease depending on circumstance
- changes day-to-day
5
Q
Steps for any HCP to be reimbursed:
A
- Pt must be injured and seek care
- Pt must be subscriber of insurance payer
- HCP must be willing to bill insurance carrier
- Carrier must be willing to pay the HCP for services rendered
6
Q
Functional Outcomes
A
- objective and subjective measurements using standardized tests/surveys
- used to determine overall effectiveness of care
7
Q
Types of Insurance Plans:
A
- Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Point-of-Service
- High-Deductible Health Plan with a Health Savings Account (HCHP)
- Medicare
- Medicaid
- Worker’s Compensation
8
Q
Health Maintenance Organization (HMO)
A
- highly restrictive, subscribers must see in-network providers
- premiums and cost share lower
- no deductibles and low copays
9
Q
Preferred Provider Organization (PPO)
A
- less restrictive than HMO
- higher premium
- deductible must be met
10
Q
Point-of-Service
A
combination of HMO and PPO
- in-network = lower costs
- out-of-network = higher costs (less covered)
11
Q
High-Deductible Health Plan with a Health Savings Account (HCHP)
A
- low premiums but high deductibles (HSA account used to pay higher deductibles)
- can see any provider
12
Q
Medicare
A
- Federal program for those 65+ years and with disabilities
- many restrictions
- ATs recognized as providers
13
Q
Medicare A
A
- hospital insurance
- hospice and home health care
14
Q
Medicare B
A
- medical insurance
- lab tests, PT/rehab services, ambulance services
15
Q
Medicare C
A
- manages care plans
- MSA
- private fee for service
16
Q
Medicaid
A
- federal program administered by states
- 2 eligibility requirements:
1. fall below certain income limits
2. disability - covered services vary by state
- many student athletes covered
17
Q
Worker’s Compensation
A
- coverage provided and paid for by employers
- covers injuries at work
- can be administered by state organization or private company
18
Q
Primary Insurance
A
first to be responsible for claim
19
Q
Secondary Insurance
A
- after primary processes claim, EOB sent to secondary carrier
- secondary schools or college settings
20
Q
Premium
A
- amount paid by the subscriber for the policy
- often paid by employer
21
Q
Deductible
A
amount the subscriber is responsible for paying before the insurance company takes responsibility for the claim
- protects insurance plan against moral hazard
22
Q
Co-Pay
A
- set amount that does not change from visit to visit
- insurance pays balance of claim
23
Q
Co-Insurance
A
- applied after the deductible amount has been met by the subscriber
- percentage of remaining balance is distributed between the insurance company and the subscriber
24
Q
Out-of-Pocket Maximum
A
total amount the subscriber is responsible for during a plan period
25
Fee-for-service
billing for each service performed rather than bundled
26
Visit rate
established amount for all services during a given visit
27
Case rate
established amount for all services provided for plan of care
28
In-Network Provider
- treat subscribers and receive a contracted reimbursement rate
- lower rate but higher volume
29
Out-of-Network Provider
- benefits more limited
- subscriber responsible for greater percentage of claim
30
Affordable Care Act (March 23, 2010)
encourages providers to form Accountable Care Organizations (ACO)
- network of providers who collaborate on patient care
31
NPI
identifies HCP who provided services
32
Current Procedural Terminology (CPT)
- identifies services performed
- indicent or time based
- provider can determine dollar amount, insurance determines reimbursement
- not provider specific
33
Health Care Common Procedure Coding System (HCPCS)
2 levels of codes
1. Level I: CPT
2. Level II: Alpha numeric
- ambulance
- orthotic/prosthetic devices
- CPT 97032 E-stim
34
ICD (International Classification of Disease) 10 codes
indicate what conditions for which the patient is being treated
35
Contracted Provider
- completes contract between themselves and insurance provider
- considered to be in-network
36
Credential Provider
- provider who completes credentialing process
- additional protection for carrier and members
- council for Affordable Quality Health Care (CAQH)
37
Explanation of Benefits (EOB)
- generated after carrier processes claim
- explains how claim was processed (how much allowed, written off, assigned to patient, paid to HCP)
38
Business
legally recognized organization designed to provide goods or services
39
Steps for opening a business
1. what and why?
2. Name
3. partners
4. type of entity
5. financial backing
6. licenses or certifications
7. location
40
Opening a Business Step 1
What and Why?
- motivating factors
41
Opening a Business Step 2
Name
- search for name or close derivative (tax ID number)
42
Opening a Business Step 3
Partners
- sole proprietor (owns business alone)
- partnership (2+ individuals join together)
43
Opening a Business Step 4
Type of Entity
- Corporation ( individuals invest money, property, or both in exchange for capital stock)
- Limited Liability Corporation (owners considered members)
44
Opening a Business Step 5
Financial Backing
- establish budget to determine first 6 months and beyond
- loan or investors
45
Opening a Business Step 6
License and Certification
- identify early
- vary from state to state
46
Opening a Business Step 7
Location
- affordable and effective
- evaluate economic trends
