Flashcards in Reimbursement and Research Deck (28):
Health Care Professional delivering services
the insurer who makes the payment for services under the insurance coverage policy
a reimbursement method that pays the provider a set fee each month, based on the number of patients enrolled in the insurance plan.
a form of reimbursement for health care services in which a health provider is paid a predetermined (fixed) amount for each patient enrolled in his or her care.
a payment for specific health care services that were provided to a patient
Medicare is a health insurance provider for...
People age 65 or older,
under age 65 with certain disabilities,
any age with end stage renal disease (perm. Kidney failure needing dialysis or kidney transplant)
People age 65 or older can apply for?
any age with end stage renal disease (perm. Kidney failure needing dialysis or kidney transplant) can apply for?
under age 65 with certain disabilities can apply for?
Largest provider of health care services in the US?
established in 1965 as part of the social security act
Medicare Part A
covers inpatient care (but not long term care), hospice and some home health care
Medicare Part B
covers doctors services and outpatient care, some home health care, DME (durable medical equipment)
Medicare Part C (medicare Advantage)
provided by private companties approved by medicare
covers same as parts A and B plus additional services amd Rx
available to those with parts A and B
Current cap for Medicare?
patient can receive 1900 in PT and SLP services in a calendar year (jan1-dec31)
the requirement to billing indicating services are reasonable and necessary to extent the cap for medicare.
extended to 3700
When do exceptions to KX modifier expire?
Functional limitations reporting at eval, and no more than every 10th visit, and at discarge (PT resposibility)
state and federally funded
provides medical and health-related services
enacted in 1965 part of social security
small copay usually required
What people are covered under medicaid?
disables, blind or pregnant
US citizen or lawfully admitted immigrant
health maintenance organizations
a type of managed care organization (MCO) that is provided by a limited number of professionals for a fixed fee
monitors and limits excessive expeditures
Must see PCP before specialists, only see providers within the network
initially created to decrease cost by providing preventative services
a variation (in regards to HMO) in which patients can visit physicians outside of the network for increased costs and can visit specialists without referral
a system in which the provision of benefits and services are controlled;administrative incentives and constraints