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46 Cards in this Set
- Front
- Back
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4 types of healthcare reimbursement
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Self-pay, insurance private insurance, employment-based private inssurance, government issurance
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self pay
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fee-for service, out of pocket
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employment based private insurance
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HMO, PPO, POS
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what is different about employment based private insurance
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It is not taxed
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Government Issurance
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medicare, medicair, worker's comp, military
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What happened between 97 and 07?
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The goal was to get emplyers to insure their emploees
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Which type of insurance is declining in number?.
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Emploee plans
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2 ways to control healthcare cost
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finance and reimbursement
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how much does the us spend on HC?
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20%
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what is finance controlled by?
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regulation (laws and rules) and competition
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how is reimbursement done?
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Providers/insurance companies say the amount that the will pay per service/visit/copayment required
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What is the theory of copayment
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To make you accountable, if something is free, you will abuse it
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balanced budget act was in response to
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uncontrolled healthcare costs and fraud
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Are most payments reimbursed through retrospective payment or prospective payment?
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Prospective payment
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what is retrospective payment
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fees negotiated after services rendered
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what is prospective payment
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negotiated before services have been rendered
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what are the 4 basic reimbursement methods
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fee for service, per visit, per case/ per episode, capitation
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what is capitation?
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a way of controlling cost from payers perspective, you negotiate to provide services per group for X amount of money, for a certain amount of time, its kind of like a per member/per month
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which is the highest risk for payer?
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FFS
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which is most rish for provider?
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capitation
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what is bundling?
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lumping tx's togther and saying youre going to give them a fee for it
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which has the most bundling
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capitation
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least amount of bundling
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FFS
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Some insurerers will not pay for what, regarding your hired personal?
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They will not pay for certain services or any service given by PTAs
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do we provide gait training or ambulation/
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gait training
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what are the buzzwords of managed care?
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effectiveness and efficiency
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what is managed care?
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A general term for organizing physicians, hospitals, and other providers into groups in order to enhance the quality and cost effectiveness of health care
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Who is always always affiliated with HMO?
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gatekeeper
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Can HMO's go outside of HMO provider and get reinbursed?
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NO
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Which is the cheapest to member?
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HMO, PPO, POS
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what does POS stand for?
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piece of shit and point of service
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What is a POS like?
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not always a gatekeeper and they may go outside of HMO; higher cost
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what is PPO?
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preferred provider organization?
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what is a PPO like?
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no gatekeeper, list of providers to go to; higher cost to go outside, most expensive to member
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What is co-insurance?
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an extra amount(a percentage) to pay for each visit
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what is the differentce between copayment and coinsurance?
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co payment is a set amount, co insurance is percentage
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what is cost shifting?
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if you insure a large group of people, you are going to have people who need a lot of care and some not, and if you shift the cost, things will balance out
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How do you qualify for medicare?
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"1. Must be a citizen or permanent resident, 2. Must be 65 years old, or, receiving Social Security for 2 years or dx. endstage renal disease
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What is Medicare A?
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You get services at hospital, snf, hospice, home health
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What is Medicare B?
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outpaitent, services, transport, durable medical equipment
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does everyone get both?
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No everyone that qualifies gets A but B you have to pay a fee
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what is DRG
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diagnosis related groups. They are in a group that medicare will pay x amount of dollars for the diagnosis, prospective paymet for a particular diagnosis
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Where does resource utilization groups?
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a SKN term, they need to assess you right away and group you into a resource utilization group and depending on what group your n , will dictate how much patient will be covered for
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What aare the specifics of medicare B?
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services must be provided by PT/PTA
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who is medicaid for?
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low income and diabled
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who is workers compensation?
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for workers injured on the job, florida funded by emplyers
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