Exam 1 Overview Flashcards
(87 cards)
ACCESS
An individual’s ability to obtain medical services in a timely and financially acceptable manner. This is determined by such factors as location of health care facilities, transportation, and hours of operation.
AT-RISK
Having to assume the financial liability for a loss that occurs when premiums paid are less than the cost of services provided.
BALANCE BILLING
The practice of billing a patient for the fee amount remaining after insurer payment and co-payment have been made.
BUNDLED PAYMENTS / EPISODIC PAYMENT MODEL
One way to reward care coordination is by providing a single payment per episode of care by bundling related costs. In this way, all providers involved would need to collaborate with each other in a way that provides a comprehensive service for a comprehensive price. This model allows for that single, standardized payment to be delivered to a care provider (or multiple providers) for all services related to a specific treatment or condition
CAPITATION
Pre-payment to a provider for the delivery of medical services to a specific population. Typically calculated on a per-patient basis, with adjustments for demographic and health characteristics of the enrolled group, this fee is paid on a fixed time schedule (eg. Per member per month) instead of a per episode of care.
CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)
The division of the Department of Health and Human Services that controls: Medicare and Medicaid payment, and policy; manages local carriers; fiscal intermediaries; and links with various state operated health programs. Previously known as HCFA (Health Care Financing Administration)
CLAIMS
A request made by a covered person to an insurer for reimbursement of health care expenses or payment of health care bills. It may also be submitted by the medical provider.
COBRA
Part of this law requires employers to continue offering health coverage for employees and their dependents for 18 months, and 36 months in some cases, after they leave the firm. Typically, the employee pays all of the monthly premium when covered by this.
COMMUNITY RATING
A method of establishing the level of insurance premium rates based on the potential health risks or claims experience of the entire population in an area.
How insurance began.
EXPERIENCE RATING
Bases premium on the “average” needs of a group (e.g. Higher premiums for coal workers, sick, and elderly). Began from competitions to bring lower premiums
COST SHIFTING
Charging one group of patients more in order to make up for underpayment by others. Most commonly, charging some privately insured patients more in order to make up for underpayment by Medicaid and Medicare.
CURRENT PROCEDURAL TERMINOLOGY CODES
Numerical codes with descriptive terms, used by health care providers and third-party payers to identify medical services and procedures performed by physicians for claims processing and payment.
DEDUCTIBLE
The annual dollar amount of covered medical expense that the insured must pay before benefits are actually provided by the third party payer.
DEFENSIVE MEDICINE
Physician practices initiated solely to reduce the risk of a liability claim (e.g., performing diagnostic tests of marginal value). Totals an estimated $20.7 billion annually.
DIAGNOSIS RELATED GROUP (DRG)
A system used by Medicare and other insurers to classify illnesses and make payments according to diagnosis and treatment. All Medicare inpatient hospital costs are determined in advance and paid on a per-case basis, according to fixed amount or weight established.
RISK: Insurerer/Medicare for # of stays
Hospital: Duration of stay
HEALTH MAINTENANCE ORGANIZATION
Prepaid health plans that provide a range of services in return for fixed monthly premiums.
“STAFF MODEL” HMOs
Hire their own doctors, who usually practice under (ONE) roof.
“GROUP MODEL” HMOs
The physicians are not employees of the HMO, but are members of a large group of practice that contracts with the HMO
“NETWORK MODEL” HMOs
An mix of the Group Model, where the HMO contracts with more than one group practice.
GROUP-MODEL HMO
An organization, such as Kaiser Permanente, that contracts for all physician services through a single group of doctors. The health plan compensates the physician group for contracted services at a negotiated rate, and the group is responsible for contracting with hospitals for care.
Advantages: Allows for tight management and offers “one-stop-shopping”; has lower capital and overhead costs than staff-model plans.
Disadvantages: Difficult and expensive to establish; limited choices may deter potential enrollees.
EMPLOYER MANDATE / PAY OR PLAY
This mandate requires employers to either offer health insurance coverage or pay a fine, which will subsidize insurance for those without access. Employers with 50 or more employees not offering coverage will pay an assessment of $2,000 per full-time employee beyond their first 30 employees.
EXCLUSIONS
Specifically listed conditions or situations that, under an insurance policy or health care service contract, are not considered as covered expenses.
FEE-FOR-SERVICE
The traditional payment system in which the physician or hospital bills the patient or insurer for each visit and service provided.
FLEXIBLE SPENDING ACCOUNT
An account that employees pay pretax dollars into and that can be used to purchase health insurance or other benefits such as day care. Typically, money in these accounts is not subject to Federal income tax. These accounts may be funded through salary reduction, employer contribution, or both.
