Chapters 12 & 13 Flashcards
(70 cards)
Who is the first, second and third party?
First - patient
Second - healthcare provider
Third - insurer
What is reimbursement?
Payment of funds by a patient or insurer to a healthcare provider for services rendered
Who is considered the payer?
The insurer
Reimbursement method that pays the provider a set fee each month based on the number of patients enrolled in the insurance plan
Capitation
Payment for specific healthcare services that were provided to the patient
Fee-for-service
Variety of methods of financing and organizing the delivery of healthcare in which costs are contained by controlling the provision of benefits and services
Managed care
What is an HMO?
Health care maintenance organization, a prepaid health care program of group practice that provides comprehensive medical care
Copayment?
Monetary amount to be paid by the patient
Deductible?
Portion of medical costs to be paid by the patient before insurance benefits begin
Denial?
Refusal by insurer to reimburse for services
Eligibility?
Process of determining whether a patient qualifies for benefits
Who pays first Medicare or Medicaid?
Medicare
What is Medicare?
Health insurance plan for people:
65 or older
Under 65 with certain disabilities
Of all ages with end stage renal disease
What are the 4 parts of Medicare?
Part A: hospital insurance
Part B: medical insurance
Part C: Medicare advantage, additional monthly fee
Part D: Medicare prescription drug coverage
Who administers the Medicare and Medicaid program?
The Centers for Medicare and Medicaid Services (CMS)
What is the Physical therapy cap for Medicare?
$1900
Requirements for Medicaid are…
Patient’s age
Patient is disabled, blind or pregnant
Patient’s financial resources
Patient is a US citizen or lawfully admitted immigrant
What part of Medicare provides for physical therapy?
Part B
Who is the PCP?
Primary care physician, acts as “gatekeeper” to decide which services the patient will receive (ie inpatient, outpatient or specialist)
HMO where healthcare providers are employees of the HMO
Staff HMO
HMO in which the health care is provided by a separate group of physicians having contracts with the HMO to treat only HMO members
Group HMO
HMO in which there are contracts between the HMO the individual physician where the physician can treat HMO and non-HMO patients
Individual practice associations (IPAs)
HMO in which there is a contract with a number of large physician groups who treat HMO and non-HMO patients
Network HMOs
Can HMOs deny physical therapy treatments even if referred by the PCP?
Yes
