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Flashcards in MRT 212 MIDTERM Deck (52):
1

Reimbursement

compensation or repayment for healthcare services already rendered

2

Insurance

Reduction of a person’s (the insured party) risk of financial loss by having another party (insurer) assume the risk

3

Risk Pool

group of people who will be covered by a healthcare insurance plan

4

Deductible

Annual amount of money that the policyholder must incur and pay before the insurance will resume liability for the remaining charges or covered expenses

5

Copayment

Sharing measure in which the policyholder pays a fixed amount per service, supply or procedure that is owed to the healthcare facility by the patient. The fixed amount may vary by service type.

6

Premium

Amount of money the policy holder or certificate holder or subscriber must periodically pay a healthcare insurance plan in return for healthcare coverage

7

Guarantor

person who is responsible for paying the bill or guarantees payment for healthcare services.

8

UCR

usual, customary and reasonable

9

CPR

customary, prevailing and reasonable

10

Self-Insured plan

method of insurance in which the employer or other association itself administers the health insurance benefits for its employees or their dependents, thereby assuming the risks for the costs

11

Third party Payer

System whereby the insurance company or health agency (the payer-the 3rd party) pays the physician, or hospital, or other healthcare provider (aka provider—the 2nd party) for the covered care or services rendered to the patient (the 1st party).

12

Indemnity health insurance

traditional, fee for service healthcare plan in which the policyholder pays a monthly premium and a percentage of the usual, customary and reasonable healthcare costs. The patient can select the provider.

13

Characteristics of Reimbursement Methods

unit of payment, time orientation and degree of financial risk

14

unit of payment

fee for service
independence/freedom
self-pay
fee schedule
more expensive/more services rendered

15

Episode of care

captitated payment
global payment
medicare home health
global surgical packages

16

Time orientation

retrospective
prospective
pre set payment example per diem payment

17

Degree of Financial Risk - patient

Less Costly-less freedom of choice
Prospective
Capitated Payment
Global Payment
Per diem payment

More Costly-greater freedom of choice Fee for Service
Self-Pay
Retrospective

18

Degree of Financial Risk -provider

Lower reimbursement rates/guaranteed patient base Prospective
Capitated Payment
Global Payment
Per diem payment

Higher reimbursement/lower volume of patients Fee for Service
Self-Pay
Retrospective

19

Degree of Financial Risk-payer (insurer)

Less financial risk
Prospective
Capitated Payment
Global Payment
Per Diem

20

Importance of proper coding

1.Communicates the services provided
2.Stable and efficient payment process
3.Compliance with guidelines and conventions

21

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Protects employees who change jobs
Electronic transmission of medical records
Patient privacy

22

Hospital inpatient procedure
Hospital outpatient procedure

ICD-10-PCS
HCPCS

23

Physician in/out diagnoses

ICD-10-CM

24

Facility hospital ambulatory in/out diagnoses

ICD-10-CM

25

Health Care Procedure Coding System (HCPCS)

Coding system created and maintained by the Centers for Medicare and Medicaid Services (CMS) that provides codes for procedures, services, and supplies not represented by a CPT (Current Procedural Terminology Code)

26

Level I

CPT codes. Copy written by the American Medical Association (AMA)

27

Coding Compliance

Fraud-Intentionally making a claim for payment that one knows to be false

Abuse-unknowingly or unintentionally submitting inaccurate claims for payment

28

False Claim Act

Civil War
1940’s
1980’s
Qui Tam-whistle blower lawsuit; person entitled to percentage of recovery

29

Office of Inspector General (OIG)-Seven elements to ensure compliance (plan)

1. Written policies and procedures
2. Designation of a compliance officer
3. Education and Training
4. Communication
5. Auditing and Monitoring
6. Disciplinary action
7. Corrective action

30

CERT

The Centers for Medicare & Medicaid Services (CMS) calculates the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program.

31

Recovery Audit Contractor (RAC)

Demonstration project required by the Medicare Modernization Act of 2003
Contracting with private business to combat Medicare fraud
Ensure correct payment for Medicare A and B claims

32

Umbrella term

which includes private or commercial health insurance plans and Blue Cross Blue Shield plans
Usually associated with employment
Payments from voluntary health plans account for 33-35% of all healthcare expenditures in the U.S.

33

Terms- Private

can mean commercial insurance (purchased); can denote insurance purchased by an individual versus an employer group

34

Terms-indivdual

private healthcare plan; not large employer based

35

Terms-group

employer based healthcare plan or group (i.e. association) based plan

36

Terms-Maximum out of pocket:

specific amount, in a certain time frame, such as one year, beyond which all covered healthcare services for that policyholder or dependent are paid at 100% by the health insurance plan; also called catastrophic expense limit or stop-loss benefit

37

Terms-formulary

list of preferred drugs; complying with formulary drugs will often reduce out of pocket expenses

38

Assignment of benefits

Agreement between provider and payer in which provider directly bills the payer on behalf of the patient. The payer directly pays the provider the allowance. Denoted on UB form FL (box) 53 and CMS 1500 box 27

39

Section of the plan

Definitions, eligibility and enrollment, benefits (maximum out of pocket expense), limitations, exclusions, procedure and appeals.

40

Medicare

1965 (implemented 1966)
*Age 65 or older
Eligible for Social Security or Railroad Retirement Benefits
Persons with permanent disability
End-stage renal disease

41

Medicare A

Part A:
Hospitalization insurance•
*Inpatient hospital•
Long-term care•
Skilled nursing services
Home health services•
*Respite care•
Hospice care-Beneficiary pays deductible and copayments after certain periods of time

42

Medicare B

Part B:
Voluntary supplemental medical insurance
• * Physician services
• Medical services
• Vaccines
• Medical supplies– *Beneficiary pays monthly premium plus annual deductible and copayments

43

Part C: Medicare Advantage (MMA 2003)

Was Medicare+Choice (1997)
– HMO
– PSO
– PPO
– Beneficiary pays monthly premiums $50–$350
– Expanded scope of services (e.g., vision services)

44

Part D: Medicare Drug Benefit

Implemented January 1, 2006
– Outpatient drug coverage provided by private prescription drug plans and Medicare Advantage
– Beneficiaries pay monthly premium, deductible, and copayments
– “Doughnut Hole

45

Medicaid

Joint program between the State and the Federal governments Provider healthcare benefits to low-income persons and families

46

Other Federal Plans

PACE
SCHIP
Tricare
-Prime (active duty)
-Standard
-Extra
CHAMPVA (disabled or deceased)
Indian Health Services
FECA

47

Managed care plan

systematically merges clinical, financial, and administrative processes to manage access, cost, and quality of healthcare

Purpose of managed care is to provide affordable, high-quality healthcare

48

Managed Care Organization (MCO)

Entity that integrates the financing and the delivery of specified healthcare services

49

Benefits which must be offered in HMO plan (evidenced based)

Physician services
Inpatient care
Preventive care and wellness
Prenatal care
Emergency services
Diagnostic and laboratory tests
Home health services
Access to mental and behavioral health and specialty care through referrals

50

Characterizations of the MCO for Quality Care

1. Selection criteria for providers
2. Delivery of continuum of care to population including health and wellness management
3. Care management tools
4. Quality assessment and improvement

51

Characterization of the MCO for Cost Effectiveness

Service management tools
Episode of care reimbursement
Financial incentives

52

Types of MCO

HMO (health maintenance organization) Gatekeeper loser costs. referrals needed.
PPO more freedom higher cost combined HMO/PPO
EPO self funded
Medicare advantage