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64 Cards in this Set
- Front
- Back
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revenue |
income; monies recieved |
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for profit organizaton |
an organization that is structured to share excess revenue with its shareholders |
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not for profir organization |
an organization with a tax status that is designed to reinvest excess revenue into the organization for the betterment of its patients (customer) |
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public health care facility |
an organization, established by a government agency, to provide health care services to its citizens |
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third-party payer |
an individual or organization who pays for a health care service yet is not either the provider or the reciever of those services |
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(CMS) center for medicare and medicaid services |
a federal government agency authorized to manage medicare and medicaid |
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worker's compensation |
an insurance plan specifically designated to pay for medical care for an individual who was injured or became ill as a result of their occupation |
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veteran's administration |
an agency of the federal government with the authority to care for members of the uniformed services |
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medical necessity |
determination that an individual has need for a procedure, service, or treatment based on the standards of care. |
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private health insurance |
a third-party payer that is not affiliated with the federal government |
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Medicare |
provides payment for health care services to its beneficiaries who are 65 or older, permanent disability, end stage renal disease (ESRD) |
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Medicaid |
for those who are indigent and low-income. |
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tricare |
federal profram that covers medical expenses for the dependents (spouse and children) of those who are currently serving in the uniformed services (active military) |
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CHAMPVA
(Civilian health and medical program of the department of veterans affairs) |
provides health care benefits to dependents of those veterans who suffered a 100% service connected disability and the dependents of those who died from service-connected disabilities |
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co-payment |
a fixed amount paid by the patient to the provider |
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coinsurance |
the patient agrees to pay a percentage of the allowed amount while the policy pays the rest |
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case mix |
a strategic plan to ensure a health care facility is caring for patients with a variety of diagnosis
**no particular third-party should represent more than 30 percent your revenue |
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deductible |
he amount of money, based on the allowed amounts, that a patient must pay out of ocket ech year before third-party payer benefits kick in. |
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(FFS) fee-for-service |
a payment plan in which a health care provider recieves reimbursement from athird party payer based on the specific procedure, services, and treatments provided. |
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(UCR) usual, customary, and reasonable |
formula used to determine the allowed amount for each covered procedure, service, and treatment |
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(UCR)
*For third parties to providers |
usual- fee usually charged by this provider for this procedure
customary- range of usual fees charged by other physicians with the same level of training and experience for this specific procedure within the same geographic area
reasonable- the justifiabe payment for the services in the eyes of the third party payer's medical review committee |
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(RBRVS) resource-based relative vale scale |
uses a unit of meaasure known as relative value unit RVU |
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Total RVUs
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work RVU + practice expense RVU + malpractice RVU |
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conversion factor |
once a year the US congress assigns a monetary value to one RVU |
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(GPCI) geographical practice cost indices |
used to make payments fair in all parts of the country |
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total RVUs * conversion factor= |
total dollars |
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total dollars * GPCI= |
allowed amount |
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episodic care |
a method of paying a provider with one lump sum based on the standard of care for a specific diagnosis |
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DRGs diagnosis-related group |
an episodic care payment plan used by medicare to reimburse acute care hospitals for services provided to inpatient Medicare beneficiaries
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DRGs |
categorizes patient care by the principal diagnosos and takes into consideraion any comorbidities and complications as well as the patiet's age and gender
severity of illness
risk of moortality resource, utilization, including the quanity anfd type of diagnostic and or theraputic services, inpatient room/bed service |
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How many DRGs are there where each medicare beneficiary's diagnoses will be sorte and calculated into the amount of reimibusrsement that will be remitted to the acute care provider |
579 |
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capitation plan |
a payment plan in which a primary care physician receives a monthly stipend for ongoing care of a manged care beneficiary |
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PMPM per-member-per month |
the PCP gets paid monthly fixed amount for every insured whether any service is provided or not |
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PQRS physician quality reporting system |
clinical basics (depression, bmi) lb and imaging test follow ups patient education and counseling
those who participate receive bonus from cms |
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(PCIP) primary care incentive payment plan |
ceated by the affordable car act to enhance payments for services provided by primry care professionals
those participating with a medicare designation as family medicine, geriatric medicine, pediatric medicine, internal medicine, nurse practitioner, clinical nurse specialist, and physician assistants may qualify |
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capital expense |
purchasing a magnetic resonance imaging MRI unit for the creation or expansion of the imaging department |
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grants |
money provided under very specific terms
not often available to for-profit
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grant |
applications are much like business plans and are extensive documents that will explain in spcific detail why the service or equipment is needed |
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CMS electronic health record EHR and HITECH |
ASSIST HEALTH CARE FACILITIES OF ALL SIZES TO IMPLEMENT TECHNOLOGY TO IMPROVE THE PROVISIION OF HEAH CARE SERVICES THROUGHHUOUT THE us |
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COMMERCIAL LOANS |
a loan provided by the bank |
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private investment
(angels) |
an individual endowing money to an individual or organization |
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endowment |
an investment with an return that goes back into the organization |
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shares of stock |
percentage of owneship in a company |
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secured bonds |
an investment backed by another asset
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debentures |
unsecured bonds supported by nohing |
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financial stability |
revenue and expenditures |
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grow business horizontally |
increasing type of services our facilty provides |
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grow business vertically |
increasing the number of patients to whom your facility can provide the same services |
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why can't administrators simply increase the charges for services provided? |
because a large portion of every health care facility's revenue is recieved from third-party payers. pay rates cannot be changed becacuse the fee is set by the payers not the facility itself |
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expenditures (payables) |
money spent or paid out |
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fixed costs |
rent, mortages, utilities, and telephone |
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variable expenditures |
debt that changes month to month.
ex: bandages, rolls of paper, and syringes, salaries |
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Emergency medical treatment and active labor act (EMTALA), the good samaritan law, physical duty to care, hill-burton act |
legal and ethical obligation to provide care nd medical services to a patient whose life is in danger without concern for getting paid or reimbursed |
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ways a physician can lose money |
rejected and denied claims that have not been corrected and resubmitted or researched or appealed for reconsideration
HAC hospital acquired conditions |
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case mix two meanings |
balanced mixed of patient diagnostic cases and balanced mix of patients cases covered by various third party payers |
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what can you do if your facility is losing money due to empty patient rooms? |
grow business horizontal and vertcally |
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the shriner's hospital and united cerebral palsy clinics are exammple of an |
not-for-profit organization |
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top three health care expenditure (expenses) |
hospitl care, physician services, prescription drgs
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what was the US 2014 expendititure |
17.9% GDP |
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cons for having no insurance |
late care, medical complications, emergency care, avoidable hospitalizations |
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501c3 |
non profit are tax exempt |
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HMO Act of 1973 (pmpm) |
pmpm |
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health maintance organization (hmo) fundamentals |
links healthcare provision to prepayment population not individual reimbursement financial risk sharing among provides, insures, and consumers intend to reverse incentives for utilization |
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capitation |
pmpm fee paid in advance whether or not service is used |
