Chapter 13 Flashcards
(12 cards)
Capitation
A system that pays providers a specific amount in advance to care for the health care needs of a population over a specific time period. Providers are paid on a PMPM basis. The provider assumes the risk that the cost of caring for the population may exceed the amount received.
Fee-for-service
A method of reimbursement based on payment for services rendered, with a specific fee correlated with each specific service.
DRGs
A system for classifying inpatients based on their diagnoses.
HMO
A legally incorporated organization that offers health insurance and medical care. HMOs typically offer a range of health care services at a fixed price.
Medicare
Federally financed health insurance program for people aged 65 and older; disabled; ESRD
- Part A: inpatient hospital insurance
- Part B: physician and outpatient services
Medicaid
Federally and state financed health insurance program that provides medical benefits to low-income people. States decide eligibility, benefits, and reimbursements.
Preferred Provider Organization
A network of independent providers selected by the payor to provide a specific service or range of services at predetermined (usually discounted) rates to the payor’s covered members
Value-based purchasing
A payment methodology designed to provide incentives to providers for delivering quality health care at a lower cost. Funds are withheld by the payer and redistributed as incentives on providers’ achievement of performance measures
Per member per month
A metric generally used by health plans and their medical providers when evaluating revenue, expenses, or utilization of services
Accountable Care Organization
A group of healthcare providers who provide coordinated care to target patient populations, with the intent of tying financial incentives to quality outcomes and lowered costs
Steerage
Technique used to influence a population used in benefit plan design by self insured and other health plans to influence or steer enrollees toward using in-network providers by offering savings in the form of lower or no copayments or deductible
Bond
A form of long-term financing whereby an issuer receives cash from a lender (investor) and in return issues a promissory note (a bond) agreeing to make principal or interest payments or both on specific dates
- Issuer wants interest rates to be low
- Buyer wants interest rates to be high
